It does seem mean that having pushed out a baby, you then have to push out a placenta. But rest assured, there are no bones in a placenta, and it is not equivalent in any way to birthing your baby!
This guide will explain what the third stage of labour is and the options you should consider when it comes to delivering your placenta.
What is the third stage of labour?
The third stage of labour starts immediately after your baby is born and finishes once your placenta has been delivered. Essentially, it refers to the time in which you deliver your placenta.
What is the placenta?
The placenta is an organ that develops during pregnancy to support your growing baby. The placenta is attached to the wall of your uterus and acts as the connection between you and your baby through the umbilical cord. It delivers oxygen and nutrients from your bloodstream into baby's bloodstream, and it removes waste products from your baby's bloodstream.
The placenta is the only temporary organ that the human body grows. By the end of pregnancy it usually weighs around half a kilogram.
What happens during the third stage of labour?
When your baby is born and placed onto your chest, they are still attached to the placenta via their umbilical cord, and initially the placenta remains attached to your uterus. During this time, standard practice is to have delayed cord clamping for at least 60 seconds (or longer if women request it), so that the baby receives the blood that is still passing between the placenta and the baby.
Once baby is born, and there has been delayed cord clamping, the placenta no longer has a function. As the uterus continues to contract down after baby has been born, the placenta detaches from the side of the uterus and is delivered through the vagina.
... top tip
It is normal for contractions to continue even after baby is born - this helps you to deliver your placenta, and helps your uterus to start returning to its pre-pregnancy state. These contractions can be painful, but remember you can still use the pain relief that you were using in labour - if you haven't had an epidural in labour, gas and air is a good choice for the third stage of labour.
Active vs physiological management of the third stage of labour
There is a choice when it comes to delivering your placenta - you will be offered active management or physiological management.
Physiological management
Involves waiting for the placenta to detach without the use of any medications, and you deliver the placenta by maternal effort (pushing).
The third stage usually lasts longer with physiological management and can take up to an hour.
Physiological management is generally only recommended when both mother and baby are well and there are no concerns about excessive bleeding.
Active management
Involves giving you a drug as your baby delivers (or very shortly afterwards) that helps to contract your uterus quickly - the precise drug differs depending on which hospital you attend, but the effect is the same. Generally, the drug is given as an injection into your arm or leg or through your cannula if you have one.
The midwife or doctor will then help to guide your placenta out, and you will not need to push it out yourself.
The main benefit of an actively managed third stage is that in uncomplicated births, active management roughly halves the risk of a postpartum haemorrhage, from around 29 women in every 1,000 to around 13 women in every 1,000. It also slightly shortens the third stage of labour.
This method can take up to 30 minutes for your placenta to deliver.
You will be recommended an active management of the 3rd stage if your labour has had any complications, for example if you have had an induction of labour, or if you are bleeding more than is normal following the delivery of your baby.
What does the midwife do during the third stage of labour?
The third stage of labour is a busy time for your midwife who will be quietly and calmly on high alert. The third stage of labour is when you are most at risk of bleeding heavily, and your midwife will:
- Help you to deliver your placenta either with active or physiological management
- Watch for signs that your placenta has detached and is ready to be delivered
- Ensure that you are not bleeding heavily
- Make sure that your uterus is well contracted by placing a hand on your tummy and making sure your uterus feels hard rather than soft
- Help you to maintain skin to skin with your baby, and assisting with baby's first feed
- Clamp and cut the cord when you are happy for this to be done
- Check the placenta once it has delivered to ensure it is complete
- Check your perineum to assess whether you have torn and need any stitches
Because you are enjoying your first moments with your new baby, much of this may go unnoticed to you - that is normal, and to be expected.
Signs that your placenta has detached
- The umbilical cord may lengthen
- You may have a small gush of blood from the vagina
- You may feel pressure and the urge to push
... midwife's insight
Breastfeeding can help you to deliver your placenta (because the hormone, oxytocin, that is responsible for your milk being released is also responsible for your uterus contracting). If you are planning on breastfeeding, it can be helpful to offer baby the breast for a feed - this helps your uterus to contract, and your placenta to detach and deliver. If baby isn't so keen for a feed, breast massage can have the same effect.
Delayed cord clamping
Delayed cord clamping means waiting before clamping and cutting the cord, rather than clamping it immediately after birth.
In the UK, delayed cord clamping for at least one minute is standard practice for well babies, unless there is a reason why baby or mother needs more urgent medical care.
Research shows that delayed cord clamping can:
- Increase baby's iron stores
- Reduce the risk of iron deficiency anaemia in infancy
- Improve blood volume and circulation after birth
- Be particularly beneficial for premature babies
Some parents choose to delay cord clamping for longer - sometimes until the cord stops pulsing completely or becomes pale and white, often referred to as "waiting for white". As blood flow through the cord slows and eventually stops, the cord changes from thick, blue and pulsating to thinner, pale and white. Some people choose to wait until this process is complete (or even until the placenta is delivered) before clamping the cord.
Possible disadvantages of prolonged delayed cord clamping
Some studies suggest a small increased chance of newborn jaundice requiring treatment with phototherapy when cord clamping is delayed for longer periods.
Evidence strongly supports delaying cord clamping for at least 1-3 minutes, but there is currently less high quality evidence showing additional proven benefit from waiting until the cord is completely white.
Possible complications in the third stage of labour
Rarely, the placenta does not deliver even with the use of drugs. If this happens, you will be assisted into theatre where your placenta will be removed manually by a doctor (and you will have excellent pain relief for this). This is called a manual removal of placenta.
As mentioned already, the third stage of labour is when you are at highest risk of bleeding heavily (known as a postpartum haemorrhage). The midwife will be monitoring you closely for this, and if they have concerns, they will be quickly assisted by the team to help keep you safe.
A note from the labour ward
Your placenta belongs to you - usually, the placenta is disposed of by the hospital. But if you would like to take your placenta home, just let your midwife know. It is yours to keep if you would like it.
Some ways that people choose to honour their placenta include:
- Planting it beneath a tree or rose bush
- Placental encapsulation, where the placenta is processed into capsules (note that current research has not shown evidence of health benefits)