The third stage of labour is the period of time between when the baby is born and when the placenta is delivered.
The placenta is the organ that has kept your baby alive while within the womb and filtered the contents of your blood so that what baby needed could be transferred through to the babies bloodstream while all of the “bad” things (chemicals, large particles that could potentially cause harm, bacteria etc) could be sent back into your bloodstream to be filtered out by your own kidneys, the babies own waste is also transferred through to your bloodstream as baby is not yet able to filter all of his/her own wastes while within the womb. Contrary to popular belief the placenta does not store what it filters out (no more than any other organ within your body stores things) – it sends everything back into your body for proper processing and filtering.
During this stage the placenta detaches from the uterine wall, with the help of uterine contractions caused by the naturally occurring hormone Oxytocin – the same hormone that, in a spontaneous labour, caused the contractions that were your “labour” – leaving an “open” wound in the uterine wall that must heal over the next month or so. The process of the uterus contracting “down” into a tight ball is what encourages the placenta to detach, the reduced space available results in the placental edges “shearing” away from the uterine wall and eventually the rest of the placenta also comes away and is able to be gently (in comparison with pushing during labour) “pushed” out.
There are two main different ways of managing this stage:
Active Management – where the woman is injected with ergometrine (a drug that causes strong contractions in the uterus and is commonly used to treat haemorrhage by making the uterus clamp down tightly) or Pitocin (a synthetic version of Oxytocin which can also cause the uterus to contract down and is also used to treat haemorrhage). Controlled Cord Traction and early cord clamping (clamping of the cord occurring less than 1 minute after birth) are commonly used during active management.
Expectant Management – where the placenta is “allowed” to detach at its own pace without any medical assistance. This can take as long as 1-2 hours after birth to occur in a physiological setting but usually occurs within the first 30 minutes after birth.
Sometimes a method of mixed management can be used (for example with someone who is at a higher risk of haemorrhage who wants a more physiological third stage or someone who wishes to have delayed cord clamping prior to active management of the placenta or if someone has planned expectant management and a haemorrhage is suddenly occurring and the placenta needs to be delivered ASAP so that the bleeding can be brought under control). Mixed management normally uses some, but not all, of the common components of both active and expectant management.
There are some complications that can occur during this stage – for more information on each of them please speak to your care provider.
- Postpartum Haemorrhage – while some blood loss immediately post birth is normal when the amount becomes excessive (greater than 500mls) it is called a haemorrhage. A postpartum haemorrhage is defined as blood loss exceeding 500mls that does not stop or slow down, a severe postpartum haemorrhage is defined as a blood loss of greater than 1000mls. It can lead to a drop in blood pressure, anaemia, tachycardia (where the heart beats faster than normal – greater than 100 beats per minute) or bradycardia (where the heart beats slower than normal – less than 60 beats per minute) and feelings of anxiety/panic and/or breathlessness.
- Retained Placenta/Membranes – sometimes the placenta may not detach properly and be retained within the uterus, or sometimes it mostly detaches but leaves a little bit of the placenta and/or the amniotic sac imbedded into the uterine wall. This can sometimes be a contributing factor to postpartum haemorrhage (listed above). Retained placenta can occur with placenta accreta, increta and percreta, and can also occur with an actively managed 3rd stage if the cervix closes before the placenta has had the chance to separate from the uterine wall or before it has been able to exit the uterus. Sometimes it also occurs during an expectantly managed 3rd stage. Treatments for this can be manual removal of the placenta/membranes or surgical removal of the placenta/membranes.
- Atonic Uterus – An Atonic Uterus is where the uterus does not contract down after birth. This can hinder the separation of the placenta from the uterine wall and can also contribute to the development of a postpartum haemorrhage. It is treated with oxytocic drugs (ergometrine and/or Pitocin infusion) and vigorous uterine massage.
- Uterine Inversion – a very rare but very serious complication where the uterus inverts/turns inside out and partially or wholly comes out through the vaginal canal. This occurs slightly more commonly with controlled cord traction which is why CCT should not be used on a non-detached placenta.
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