Third Stage of Labor Decisions - What You Need to Know
“I need to give you a little injection so you don't bleed to death….”
Whoa….what the ???? These aren’t exactly the words you expect to hear immediately after your freshly born newborn is being wiped down in your arms as your body is flooded with oxytocin and endorphins, relief and disbelief.
But this is what I heard at a beautiful hospital birth I supported. It was a powerful, incredible tiring first birth for these parents. Mom labored at home for several hours and arrived at the hospital only 50 minutes before I heard mom start to bare down with those irresistible urges. The pushing stage lasted another hour with mom just going with her body changing positions frequently to help move her baby through her pelvis.
This was a fit, healthy full term mom who had just had a very normal, physiological labor and birth so why the scare tactics now? (Especially when both parents had discussed their preference for a physiological 3rd stage of labor with their OB who unfortunately was out of town for the birth). Mom had a history of mood disorders in her early 30s and was keen to avoid synthetic oxytocin unless it was medically necessary - i.e. if she was indeed starting to bleed to death. Recent research suggests that synthetic oxytocin (Pitocin/Syntocinon) is associated with more postpartum mood disorders including anxiety and depression.
If you’re having a hospital birth it’s assumed that you have agreed to have a managed 3rd stage of labor. But most parents I speak to have only been told that like the title “it’s so you don’t have a hemorrhage” – and that sounds quite reasonable to any sane human. But often no alternative is offered as an option for parents to consider. But if you’ve read some of my other blogs you’ll have noticed a theme of selective information being given to some parents.
How Much Blood Are We Talking About – Tarantino Levels?
In some hospitals blood loss of 500mls or more is considered a PPH (postpartum hemorrhage) but we now know that 300-500mls is quite normal for a healthy mom and it may have no impact on her postpartum recovery at all. Another mom may lose 200ml and have a more challenging recovery. More and more medical professionals are calling on the definition of a PPH to be raised to 1000ml (ask your careprovider how they define a PPH).
“If you were to donate blood tomorrow you would give about 480ml – almost the same as what’s considered a PPH. Keep in mind that during pregnancy your blood volume has increased significantly also”
What Are My Options for Delivering My Placenta?
There are 2 approaches to how your placenta is delivered.
Active Management
Injection of a uterotonic (a drug to contract the uterus) - synthetic oxytocin or if you have an IV of Pitocin or Syntocinon already running it will continue.
Immediate cord clamping (some hospitals will delay cord clamping as part of this ‘package’).
Controlled Cord traction to pull out the placenta (some moms find this very painful and there’s little evidence to show it reduces bleeding). The cord is also at risk of breaking which means mom may need to have a manual removal of the placenta in theatre.
More About Active Management of the Third Stage
If you are bleeding excessively the medication can help your uterus to contract more so the placenta ‘peels’ off the wall of the uterus and falls into the bottom part of the uterus and your careprovider can then pull it out. Depending on the drugs used some moms can experience vomiting and high blood pressure. Some small studies also suggest an association between some of the drugs used for active management may impact breastfeeding due to action on prolactin receptors.
Physiologic/Natural Third Stage
(Also known as expectant management - a wait and see approach).
Mom and baby have skin to skin and breastfeed. No uterotonics are given and mom is encouraged to move position (sometimes to sit on the toilet) and the placenta falls out into a bowl.
If a mom has had a straight forward healthy labor and birth evidence suggests a natural 3rd stage is a reasonable option. A 2012 study from NZ suggested that women experienced less blood loss in a natural third stage compared to healthy moms who had a managed third stage. More moms had blood loss of over 1000mls in the active management group than the physiological group.
After your baby is born bleeding doesn’t always come from the uterus – it’s categorized into one of the following:
Tone – is the uterus contracting properly to reduce bleeding?
Trauma – is the bleeding coming from a tear/episiotomy or cesarean?
Thrombin – does mom have blood clotting complications?
Tissues – retained placenta or membranes
An important aspect to keep in mind is that if you are diagnosed with a PPH (even at 500ml caused by an episiotomy) it may impact your options for your next birth. Ask your careprovider how they define a post partum hemorrhage.
What Does the Research Say?
There have been several trials comparing active management of the 3rd stage with a natural 3rd stage but they weren’t considered high quality and many of the staff had experience with a natural approach. The Cochrane review suggests that there isn't that much difference between active management or physiological placental birth for healthy women who have had no medical intervention during labor.
Authors' conclusions:
Although the data appeared to show that active management reduced the risk of severe primary PPH greater than 1000 mL at the time of birth, we are uncertain of this finding because of the very low-quality evidence. Active management may reduce the incidence of maternal anaemia (Hb less than 9 g/dL) following birth, but harms such as postnatal hypertension, pain and return to hospital due to bleeding were identified.
In women at low risk of excessive bleeding, it is uncertain whether there was a difference between active and expectant management for severe PPH or maternal Hb less than 9 g/dL (at 24 to 72 hours). Women could be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management. Data are also required from low-income countries.
It must be emphasised that this review includes only a small number of studies with relatively small numbers of participants, and the quality of evidence for primary outcomes is low or very low.
“In women at low risk of excessive bleeding, it is uncertain whether there was a difference between active and expectant management for severe PPH or maternal Hb less than 9 g/dL (at 24 to 72 hours). Women could be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management. Data are also required from low-income countries”
Who is Most at Risk of Having a PPH?
A hospital birth
A long labor (or a very fast labor)
Labor induction
Instrumental birth (forceps/vacuum)
Episiotomy
4kg+ baby (but we have no way to accurately predict baby’s size)
Your overall health (any blood clotting disorders?)
Cesarean birth
Just because you have a risk factor doesn’t mean it will happen on the day but if this is important to you discuss with your OB/Midwife about your individual circumstances and preferences.
How Can I Reduce my Risk of Bleeding Excessively
Prepare for a low intervention birth (not always possible but stack the odds in your favor).
Immediate skin to skin with your baby.
Breastfeed as soon as possible after birth.
Mom is kept warm and room kept quiet (high stress levels are associated with more blood loss).
Minimal fundal fiddling (repeated unnecessary fundal checks are very common in US hospitals after birth).
Placenta delivered by maternal effort and gravity.
Even if you choose a natural 3rd stage and you did begin to bleed more heavily the drugs will be sitting close by to administer in seconds so it’s not like you can’t change your mind! The staff will be watching closely too especially if they don’t have experience facilitating a natural 3rd stage.
My client declined Pitocin after Dad asked a few critical questions and both mom and baby were healthy and well on discharge 2 days later.
As always - talk to your careprovider about your options and keep a flexible mindset if things need to change on the day.
What was your experience of the 3rd stage of labor?