The following is a student blog post by Miriam Halliday
Writing a Plan for the Third Stage
Childbirth involves three stages, the first is the onset of labor and lasts until the cervix is fully dilated to ten centimeters, the second stage involves the baby moving through the birth canal and ends when the infant is born. The third and final stage, often the shortest stage, is when the uterus continues to contract and delivers the placenta. It is this final stage which I want to draw attention to.
Most women plan and prepare a lot for the first and second stage of labor as it is the most emotionally and physically taxing. This planning involves deciding on a care provider that supports the kind of birth that the laboring person wants, whether that be a home birth with no medicine for pain relief, or a hospital birth with options for an epidural and IV pain medication. The expectant mother will ask friends and family how their labor went and will often be curious as to how contractions feel and if she will be able to manage the pain with no medication. She may take childbirth classes in order to prepare herself for labor so that she and her partner can anticipate what it may be like and have a game plan for coping with the physical demands of labor. A birth plan may be written with details about the atmosphere she wants, the pain management she desires, and the options she would like during labor.
Unfortunately little attention is given to what happens after the baby is born. The mother has just delivered the baby, with or without pain medication, having worked hard and is gazing at her child in bliss and happiness. Feelings of triumphant joy swell in her as she kisses her newborn and marvels at the life her body so perfectly made. The classes paid off and the hours of labor are over, her well researched birth plan has come to an end… But has it?
At this point the care provider may continue to be between the mother’s legs, pitocin is administered via IV or intramuscular injection as they use cord traction to remove the placenta. The placenta may or may not slide out easily, the provider may choose to tug harder and harder to remove it. There is a calm chaos in the room as more nurses filter in and start to aggressively massage the fundus. The mother may be writhing in pain at this point, unable to focus on the baby feeling bewildered and flustered. The provider may tell the mother to just look at the baby or try to nurse but with all the commotion and the grinding hands it doesn’t come naturally or intuitively. If there was tearing the provider will start to repair the tear by assessing the damage and preparing to suture. Shots of lidocaine will be given for numbing if the mother did not receive an epidural. Mother and baby are in the sacred first hour after birth as this is happening yet most third stages are rushed, filled with an air of urgency and nervousness causing pain, confusion, and sometimes trauma to the mother. So why is it this way? Why don’t providers let nature take it’s course and wait for the placenta to be delivered without any intervention? Why not let there be peace and serenity following the birth of the baby? Why not delay the cord cutting and preserve that “golden hour”?
Well, according to the World Health Organization, postpartum hemorrhage or PPH, is the leading course for maternal deaths globally. This third stage is the most dangerous time
statistically for the laboring person. ACOG (The American College of Obstetrics and Gynecology) states, “In an effort to reduce the incidences of postpartum hemorrhage, there are three components for active management of the third stage of labor: oxytocin administration, uterine massage, and umbilical cord traction.” These three components are recommended to reduce postpartum hemorrhage and are probably also popular due to the fact that a managed third stage is shorter in most cases than relying on the bodies natural contractions to deliver the placenta. However various studies say that cord traction is not evidence based and has not reduced PPH. The Gülmezoglu study states; “Our findings suggest that omission of cord traction results in very little, if any, increased risk of severe hemorrhage.” And the Deneux-Tharaux study says, “In a high resource setting, the use of controlled cord traction for the management of placenta expulsion had no significant effect on the incidence of postpartum hemorrhage and other markers of postpartum blood loss. Evidence to recommend routine controlled cord traction for the management of placenta expulsion to prevent postpartum hemorrhage is therefore lacking.”
In a physiological third stage of labor the woman is bonding with her baby with skin to skin contact, they smell each other and sometimes the baby latches and starts nursing. All of these actions are a carefully orchestrated hormonal dance that stimulates the release of oxytocin from the posterior pituitary gland and causes contractions that expel the placenta. If the dance of hormones is interrupted or messed with things don’t always play out in a favorable way.
Dr. Rachel Reed, a senior midwifery lecturer says this, “The bottom line is that the birth of the placenta and haemostatsis (prevention of excessive bleeding) relies on effective uterine contraction. Ineffective uterine contraction is the main cause of postpartum hemorrhage (PPH). The other causes are perineal/cervical damage, or even more rarely clotting disorder.”
Obviously a more relaxed and peaceful approach to the third stage sounds much more appealing but realistically it may only be safe for a mother that has had a physiologic birth with care providers that are comfortable with staying calm, using soft voices and dim lights to keep the space inductive to the release of oxytocin, and effective contractions. Perhaps this will not be on the cards for everyone, especially if labor had to be induced. Reed goes on to say, “There are 2 main causes of ineffective uterine contraction after birth: 1 Hormonal – Inadequate circulating oxytocin or inadequate uterine response to oxytocin. Inadequate response is often because the oxytocin receptors in the uterus have become saturated eg. by large doses of syntocinon over a long period of time during an induction (Belghiti et al. 2011; Phaneuf et al. 2000). 2 Mechanical – something is in the way and the uterus cannot contract. Most often this is a full bladder taking up space in the pelvis and stopping the uterus from contracting down. It can also be a large clot in the uterus or a partially detached placenta.”
The expectant mother should think through this stage as the choices made in labor could directly affect how smoothly the third stage goes. For instance if a laboring person desires an unmedicated birth in a hospital but receives augmentation to speed up her labor she may need
more interventions down the line when it comes time to deliver her placenta. I have seen women have completely unmedicated births where their wishes were supported but once the baby was born the care provider believed that the mother had fulfilled her wish for an unmedicated birth and now it was their job to make sure they didn’t bleed to death and implemented all the interventions at their disposal. There is a lot of fear surrounding this stage so it is important for the mother to understand the risks as well as the benefits and to advocate for herself before she is in that situation. The benefits of delayed cord clamping have been well documented and ACOG guidelines recommends delayed cord clamping for all healthy infants. Nobody wants to be yelling at their doctor to leave them alone while they’re exhausted and trying to bond with their baby. Simple instructions in the birth plan can avoid this such as, “If baby is healthy place baby immediately on abdomen. Please do not rush Third stage/delivery of placenta and no cord traction. Please do delayed cord clamping and keep the room calm and quiet to allow mother and baby to bond and start to nurse. Do not rush suturing if there is tearing. Please make sure Mother and baby are comfortable and settled in before proceeding with repair.” Obviously, like anything in a birth plan, this is all with the expectation that things are going well and nothing alarming has happened. By adding slightly more thought and detail into this third stage of labor the mother is more likely to avoid being blindsided in her most vulnerable moments following birth.
Communicating with her care provider and talking through the birth plan is always key to better emotional satisfaction. The laboring mother will never forget the moments after labor is over, what should remain with her is the wonder and joy of holding her new family member.
 http://www.who.int/medicines/areas/priority_medicines/Ch6_16PPH.pdf  https://www.acog.org/About-ACOG/News-Room/News-Releases/2017/ACOG-Expands-Reco mmendations-to-Treat-Postpartum-Hemorrhage  https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60206-2/fulltext  https://www.bmj.com/content/346/bmj.f1541  https://midwifethinking.com/2015/03/11/an-actively-managed-placental-birth-might-be-the-bes t-option-for-most-women/  https://www.acog.org/About-ACOG/News-Room/News-Releases/2016/Delayed-Umbilical-Cor d-Clamping-for-All-Healthy-Infants
Author Bio- Miriam Halliday is a birth doula in the Pacific Northwest, she is a mother to a 7 month old baby boy and a dog mom to her Pit Bull and Shih -Tzu. She grew up in the U.K until she was 14 when she immigrated to America with her mum and step-dad. Her love for birth started early with the birth of her younger brother at home in England with a midwife and later on another home birth with her sister. Miriam is one of five children and now a mother herself, babies and birth have always been a part of her life. When she is not attending births and helping women postpartum she enjoys snowboarding, hiking, cooking and reading.
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