3rd stage - best way to minimise time spent pushing out the placenta?

[digitalgirl]

First time round I asked for a managed 3rd stage. I was exhausted from pushing DS out and thought having the injection would help my body push it out for me. Well, just like DS my body refused to do anything. So after a bit of tugging from the midwife who stopped when she could 'feel something tearing' I had to gather up my last remaining strength and push the bloody placenta out or would have to be wheeled into theatre. Took 30 mins, which I know isn't that long compared to the 2 hours of pushing DS...but I wondered if maybe I'd waited for the cord to stop pulsing before cutting it, or maybe there was something else I could have done, like had more skin to skin before attempting to push it out?

Does anyone know?

I also wonder if I had a tiny bit of retained placenta because it took over a week for my milk to come in and that was only with 3 hourly expressing. Once DS had started feeding properly I passed a massive clot.

Sorry, feel like I'm being a bit needy on this board - this is my second thread in as many days.

It depends really.

Having a managed third stage means it's probably going to be quicker for you to deliver the placenta - but the clock is ticking once you have the injection because the cervix closes and you could end up with a retained placenta. Usually you have about 30 minutes.

If you don't have the injection, you can just leave the cord and placenta alone.

I'll copy and paste a couple of posts I've put up in the past about a managed third stage vs a physiological third stage, hopefully they'll help?

Advantages of natural third stage (disadvantages of the injection):
You have longer to get the placenta out - a placenta trapped behind a closed cervix (which can happen once syntometrine is given) can contribute to PPH and therefore the risk of retained placenta and needing manual removal is reduced.

Fewer drugs in your system

No-one can take baby away for cleaning up/weighing etc as they're still attached to you

Baby gets full amount of cord blood

Disadvantages of a natural third stage (advantages of the injection)
Increased risk of PPH if your uterus doesn't contract efficiently once baby is born (although syntometrine can be given at any time, it doesn't have to be within seconds of the birth)

Shorter time to deliver placenta once injection is given so you're on a shorter clock although it is usually effective at delivering the placenta fairly quickly (however if it hasn't been delivered within so many minutes afterwards then you may need manual removal)

Breastfeeding immediately (if you can) and being left to bond with your baby are actually meant to help deliver the placenta - the oxytocin release helps the uterus to contract and encourages the placenta to shear off.

Some midwives aren't comfortable with physiological third stage or aren't aware that they shouldn't touch the cord or apply gentle traction to it without drugs.

If you're having a physiological third stage, the idea is to 'watch and wait' - some MWs don't seem to be entirely comfortable with that and feel that you 'should' be doing something to help things along (ie changing position and pushing), when actually the best thing to do is observe and then suggest the injection later if doing nothing doesn't work.

Prophylactic use of syntocinon (one of the drugs used) has been shown to be less effective when used in subsequent pregnancies (eg if you have it 'just in case' in one pregnancy, then it is less effective next time it is used) - I think that research was done by Professor Cecily Begley at Trinity College, Dublin. Her research also showed that there was no increased risk to mothers from watching and waiting and administering syntometrine if it was necessary as it still only takes a few seconds to get into the system.

I've looked into this a lot as I had a PPH and retained placenta first time round, and am planning a homebirth with physiological third stage this time round. The Supervisor of Midwives didn't disagree with anything I said to her about the above

Hiya digi,

If you remain upright, cuddle your baby - perhaps even feed, delay cutting cord for as long as possible, even until after the placenta has been delivered and treat the who 3rd stage as a chill out time with your baby, it will take less time, as your hormones will be best places to finish up. If you get anxious, feel rushed, are separated from your baby, this will work against the process.

Hth

Hi digi!! I can only talk anecdotally but I waited until the cord finished pulsating then I sat on the loo to deliver the placenta (inco pad underneath the seat). I know a couple of other ladies that did it like that too, maybe sitting on the loo helps you push it out?

Agree with Starlight- that's how it worked for me.

Second time around, the mw pushed a pressure point somewhere on the top of my shoulder and that seemed to speed things up. I don't remember having to push much with any of them though.

Thanks, really interesting responses - and thanks for the cut and paste fliss. Maybe I will see if we can wait for the cord to stop pulsing first and do a physical third stage. But, yes, I do need to discuss this with my MW.
Although, not sure what the likelihood of getting an appointment with her this week is. My own fault for not really thinking about the birth and my birthplan till now...36 weeks tomorrow!

I've had three dcs first I had injection delivered placenta in around ten minutes, 2nd decided to go down the natural route, 59 min later lots of pacing around sitting on loo etc placenta finally arrived a minute before I was about to be blue lighted to nearest consulting hospital! Wouldn't have been great after a straight forward homebirth, was really uncomfortable will doing first feed aswell as the cord was short and felt like it was being pulled while I was using to bf.

3rd had injection again delivered placenta quickly, may just be coincidence but i'm due in 5 weeks and will have injection again.

Threecurrantbuns - I had a similar experience with my last birth....placenta also took just under an hour, no drugs, homebirth. I did quite a lot of research into it as wondered what to do this time around....managed 3rd stage or not.

Talked to one midwife who seem to have been told an hour is the maximum it should take, but equally to several midwives who said that they wouldn't be concerned with 2 hours or more. I think there seems to be some confusion in guidelines - probably not helped by the fact that most people have managed 3rd stage (which is more time critical...an hour after having syntometrin would be a big cause for concern) and let's face it the whole thing is probably partly, understandably, driven by the desire to get the midwife's job done and dusted.

But certainly the impression I've been given is that they wouldn't transfer me anywhere for needing to get the placenta out before 2-3 hours with a physiological 3rd stage. I also think that last time the pacing around and midwife stressing contributed to taking a while - this time I am happy to sit on a bucket but I'll do so breastfeeding my baby.

One injection three physiological third stages. I had a terrible time trying to get the placenta out first time, catheter, hanging over a bed pan, MW tugging on it, almost in theatre.

Second time delayed cord cutting baby feeding still attached, pushed it out in about 20 mins after the baby.

Same with third.

I did notice that with my 4th who was born in hospital the MW was really uncomfortable with the delayed cord cutting and physiological third stage probably as she wasn't used to it, love that they cannot take your baby away, they are on your chest attached to you snuggling and all anyone else can do us watch. The MW kept watching the clock I think she was bored and wanted to get on with things!!

According to the AIMS book 'birthing your placenta' the 1 hour 'limit' for a physiological third stage is a completely arbitrary time frame - ie there's no evidential basis to it!

They didn't cut my cord for a long time either and I was bf for about 50min until they started to seem worried and asked me to get mobile sit on toilet etc as needed it out asap.

Was my midwifes suggestion at the time to not half injection as at the time new research was suggesting it may not help. Was all a bit confusing really, but for me I much preferred it out asap and still had my baby straight away and didn't let go for at least an hour for weighing etc.

Plus trying to push a placenta out after labour just didn't feel right couldn't push, nothing to push against and felt like I was going to push my insides out lol

But you don't have to 'push' the placenta out. No point either if it isn't attached yet. You just wait, rest, have a cuppa, feed your baby and it will drop out by itself.

I think my mw asked me to cough at one point, to see if it was ready, and splosh, there it was. An hour or two passes in no time if no-one is watching the clock and tapping their feet and you are resting and getting to know the baby. There really is no rush.

I know that is what I was doing until we started to approach an hour, and then the midwife seemed concerned and started saying can you give a little push, can you try sitting on the toilet etc. Made me feel a bit anxious and desperate to just get it out.

I second the suggestion to cough - i think your pelvic floor completely relaxes when you cough. Worked for me, had it in my birth plan.