These archives contain extracts from discussions held on the UK Midwives and Consumers email list, a discussion group for people interested in midwifery in the UK. Open to midwives, students, mothers, and anyone interested in improving maternity services in UK. Posts in these archives express the views of the individual authors, and not those of the Association of Radical Midwives.
Cutting the Cord - or not! - cutting, clamping, and lotus birth.
Emergency management of haemorrhage at home births and in hospital
Grand multiparity and PPH risk
Implications of low haemoglobin levels/anaemia, including:As a student midwife and going through my fourth pregancy, can anyone clarify to me the advantages of having a physiological third stage of labour over having syntometrine? I have read various things but have yet to be convinced that there is a marked advantage of having a physiological third stage.
Just to take this back to basics.......injections hurt!
If my body can do something just as well, if not better, without having to suffer an IM (intra-muscular) injection, there's no competition!
Tikki
Syntometrine often causes nausea and vomiting, as well as elevated blood pressure. Which is why we only use syntocinon for 3rd stage management.
Kirsten
Apart from the physiological effects - and not everybody suffers from nausea, or raised blood pressure, as a result of syntometrine administration - the reason for deciding to have a physiological third stage for me would be twofold.
Firstly, if an oxytocic drug is not given, there is no rush or hurry for third stage to be completed. This means that there is, or should be, plenty of unhurried time to greet and explore the new baby. No haste to cut the cord and separate the baby, no worries if the baby takes its time before it takes its first breath, just space to begin to get to know each other. The longer I work, the more I believe that those first precious minutes are irreplaceable and sacred.
Secondly, for many women, birthing is a journey of self-discovery, where they find strengths and resources in their body they didn't know existed. It's an important lesson, to find out that your body can be trusted. If you rely on an outside agent to complete third stage, you are messing with that journey.
Of course you can always sit on the fence if you aren't sure, and ask the midwife not to give the injection straight away, but to wait until the cord has finished pulsating and the baby has been separated, usually between ten and twenty minutes following birth.
Melanie
Independent Midwife
Personally I think there has to be a marked advantage to having intervention, rather than a marked advantage to not having it, so I chose not to have syntocinon or syntometrine for the third stage unless it was indicated. It would seem a bit bizarre to have an unmedicated, natural labour and then have routine intervention at the end. I also did not want to risk common side-effects of nausea and headaches in those precious moments when I was getting to know my baby.
My mother's managed third stage in 1994 led to the cord breaking under CCT, then trapped placenta because of the ergometrine component of syntometrine presumably. This required manual removal under topped-up epidural which took up the first hour after the birth, during which time she was bleeding everywhere rather than cuddling her baby. She was offered (but refused) a transfusion, and recovered well. Trapped placenta is of course a known side effect of active management of third stage.
When I looked up research on third-stage complications associated with active management, though, I found that it was difficult to find helpful data because of some of the definitions used. For example, some studies define 'retained placenta' as one which has not been delivered 30 minutes after the birth. While this might be a problem in a managed third stage, it's perfectly normal in a physiological third stage. This means that what you might consider 'problem' retained placentae, some of which will be trapped, from managed third stages, are lumped together with perfectly normal physiological third stages. Some of these studies then conclude that physiological third stage results in more 'bad outcomes', ignoring the fact that most of those placentae from physiological third stages will turn up with no trouble at all, whereas those retained after managed third stages may well require major intervention to remove.
After my first birth I had what I now consider a semi-physiological third stage, in that no drugs were used, but the cord was cut when it stopped pulsating. I then sat around for an hour or so feeling bored and lonely before the placenta turned up. My husband was cuddling the baby, and kept bringing him to me but I felt that I wanted to 'get this over with' before I could relax. It was entirely my own fault, but nonetheless it felt like I was getting on with the messy business while everyone else was celebrating the birth! Blood loss was over 500ml, mainly large clots that had built up behind the placenta after the birth and which all came out in a gush just before it was delivered. I felt fine, was out shopping the next day, and had normal Hb three days later.
Second time around, I had read that some midwives believe that it facilitates a physiological third stage if the cord is not cut until the placenta has actually been delivered. I read about this on the Midwife Archives at http://www.gentlebirth.org/archives/cordIssues.html .
They speculate that cutting the cord can slow the delivery of the placenta and increase maternal blood loss because somehow the body's natural feedback system is interrupted. Sounded sensible to me though - after all, from an evolutionary point of view, I thought it unlikely that our ancestors would have been biting through the cord before the placenta was delivered.
I decided to try this fully physiological third stage, on the grounds that, no matter how antisocial I felt after the birth, I would be tied to my baby and would be forced to spend that time cuddled up to him. It worked wonderfully, and I was somewhat disappointed when the placenta duly turned up after only 10-15 minutes and a quick push! When you do this, no-one can come between you and your baby. He can't be passed around, or cleaned up, or weighed or measured. You might have written in your birth plan that you don't want any of these things done until you're ready, but sometimes people forget, or don't want to make a fuss, and will just go along with the flow. It's a great way of protecting those precious moments. At this birth, I had a 3rd stage of 10-15 mins and estimated blood loss of < 100ml. Of course, there's no way of knowing how much the delayed cord cutting contributed to that improved outcome - I was at lower risk of blood loss anyway as it was my second baby and he was a lot smaller - but certainly psychologically it was vastly preferable.
Angela
I have had physiological third stages with all my homebirths, which were my 3rd child through to my 7th child. I think for me to explain the advantages it would be easier to explain the disadvantages of when I had a managed third stage with my first and second child.
Firstly it starts with a ghastly jab in the thigh just as you're trying to concentrate on birthing your baby (despite what others say you DO notice it). Then there is the rushing of cutting the cord, and the urgency to get the placenta out. Instead of being able to focus on my baby, it's all this tugging and looking at my fanny to see if it's coming, the 'c'mon you need to give a push we have to get it out' panic.
Compare that to birthing my baby unhindered by needles, then watching in awe as my wonderful life sustaining placenta and cord which has done such a marvellous job thus far, slowly allows my child the time to ease into its first breaths while giving it the back up of its own oxygenated blood still. When my clever placenta knows my baby has got the breathing thing under control it finally lets go and stops pulsating, then I'm free to sever the link myself. I can cut my baby's lifeline and separate him from my body. My Baby then suckles at my breast, which in turn stimulates my uterus to contract and shear off and push out my placenta all on its own. No hemorrhaging, no panic, no rush. I feel a lump in my vagina and give a gentle push, it's all over.
None of my third stages have taken longer than twenty minutes and my most blood loss has been 200mls (est) the least 50mls. With the synto injections with my first two the delivery of the placenta still took 30 mins and my blood loss was higher - 300 and 350 mls. With the twins, Rose's (twin 1) placenta birthed before Amelia (twin 2) was born, which was nice as then I knew whose was whose! We let her cord also stop pulsating before we cut it. Amelia's placenta was born about 5 mins after her ( again we let the cord clamp off on its own before cutting it.) I had lost an estimated 500mls, which wasn't a problem, but due to the over-stretching and being babies 8 and 9, I had synto put in the I.V after Amelia was born and we had cut the cord. Interestingly I immediately felt nauseous and dizzy, I was told it was probably the blood loss but I think it was the synto.
Andrea - Mum of 9
Read:
1. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour (Cochrane Review). In the Cochrane Library, Issue 2, 2000. Oxford: Update Software.
2. Gyte GML. evaluation of the meta-analysis on the effects, on both mother and baby, of the various components of "active" management of the third stage of labour. Midwifery. 1994. 10:183-199.
3. Rogers J et al. Active versus expectant management of the third stage of labour: the Hinchingbrooke randomised controlled trial. Lancet. 1998. 351:693-699.
....and take it from there. The bottom line is that a normal physiological third stage of labour most likely follows on from a normal physiological first and second stage of labour. Unfortunately, too many trials have included women who have not achieved the latter when trying to assess the former (if you see what I mean!)
Julie Frohlich/MIDIRS
I don't want to sound cynical...but to my knowledge active management of third stage has been one of the biggest factors in reducing maternal morbidity and mortality in the 20th century.
Third stage management has certainly been a lifesaver this century for countless women who have had their birthings managed by the medical model, which fiddles, interferes and lacks patience - all factors which disturb the natural physiology of labour and third stage.
Active management is necessary and appropriate for labours which have had medical intervention of almost any kind, and sometimes for others like grand multiparity, very rapid births - I really am not going to go through the list. Drugs to control third stage bleeding are a standby lifesaver at every birth, ready to be used if indicated. Physiological births without active management or interventions are usually followed by problem-free physiological third stages in my experience (personal observation, rather than generalisation). Behind delivery-room doors there is very limited knowledge of one another's third stage clinical practice. Theory is one thing, what midwives and doctors actually do is quite another. It is well known that any halfway house between active management and physiological management of third stage is worse than either, and yet that is what happens time after time. Thank goodness for drugs to control bleeding in those circumstances. But don't let's go over the top and damn physiological third stage altogether.
Physiological third stage is our usual practice, and over the last five years use of the drugs has been indicated on only a handful of occasions - perhaps three or four times a year.
Of course the drugs need to be there, and ready for use. But they should not always need to be used.
Melanie
The most recent research with regard to active versus physiological third stage is below:
Rogers J et al.
Active versus expectant management of the third stage of
labour: the Hinchingbrooke randomised controlled trial.
Lancet. 1998.
351:693-699.
As midwives working at the unit at the time we were very involved with this research and many of us were sad that the outcome was not in favour of physiological - 8% PPH Active versus 11% PPH Physiological (I think). The midwives at Hinchingbrooke, certainly at that time, were experienced in physiological third stage 'management' and any who weren't had good training sessions. So I believe the conditions were optimum for this kind of trial.
However, despite the higher risk of PPH, there are many benefits of physiological third stage which have been mentioned on this list. Athough we may be disappointed that research doesn't back up our own experience or heartfelt beliefs, surely the point is to be able to make informed choices.
A midwife from Hinchingbrooke
I believe that women are not given informed choice in regards to the third stage of management. It seems to have become such standard practice to give syntomentrine, even though we know it has some horrible side effects; most women accept the injection.
It only seems to be women who have explored the issue because of the side effects that they experienced the first time that they then explore their options and possibly choose not to have synto.
I have deviated from our protocol a few times. However one woman had a primary pph 12 hours after delivery and what was the "excuse"? ...... she did not have syntometrine......! I don't believe that this is correct because her pph may have occured even with syntometrine - you just do not know.
Therefore I will keep offering women choice even if I have to face that stigma for them.
Pro choice!!!
Robyn
As far as 3rd stage is concerned, I adopt a wait and see approach, unless the woman wants me to do anything else. I always, if there is time, draw up the synto. Nothing like an exsanguinating woman to spark of a bit of adrenaline and I'm not good at fiddly things when I need a steady hand! I very rarely use synto at home or in hospital and in two years or regular practice, I have never had a PPH following this management. It has become second nature for me.
Libby
You may be surprised to know that it is considered to be almost malpractice in the US to give any oxytocics before the placenta has delivered. Except with an induction of course
.They have no problem with cord traction or hellacious fundal pressure, but the pit drip is standard of care only AFTER the placenta is delivered. They truly think that my clients (who demand no IV and no post partum pit drip) are asking to die of a post-partum hemorrhage. I have seen the nurses attempting to put an IV in a woman throughout her 20 minute second stage because the doc had the dad so scared he insisted they do so against his wife's wishes.
Of course the fact that the drip enables them to ignore the mothers bleeding postpartum means that I have to remind the nurses to check the mums fundus occasionally.
Angela C - midwife in the USA.
My impression is that physiological 3rd stage isn't being done because midwives haven't done it.... in my first pregnancy, my community midwife warned me that few midwives would have experience, that in her 16 years of practice (she was a supervisor) she had only done 3 and one of those was where the placenta immediately followed the baby.
Ironic, isn't it? The 'radical' approach to third stage is the one where the midwife doesn't usually have to DO anything! It seems so strange to talk of not having 'done' a physiological third stage, when all it requires is that you sit on your hands and keep an eye on the proceedings!
At the births of my own two babies, the midwives didn't 'do' anything apart from 1 initial internal exam, check the baby's heart and my pulse/BP during labour - and take the baby when I decided to hand him over. No 'delivering' or catching the baby, guarding the perineum, fundal fiddling, drug administration at any stage of labour, no cord traction, no nothing. They were just there to keep an eye on me and the baby while I got on with the job. This seemed completely normal to me, but I'm now starting to wonder how often it happens elsewhere.
A Mother
Finally got the chance to carry out a physiological third stage (with a midwifery student) yesterday. Lovely birth, mother on hands and knees, babe to mother for cuddle in hope she would breast feed straight away, cord left to stop pulsating - clamped and cut by father 10-15 mins later(placental end of cord not clamped). Babe given suction and O2 in mother's arms as slow to breathe. Still on hands and knees with bed pan beneath her bottom (but not sitting on it) I handed babe to Dad as Mother feeling tired, pulse 90 bpm.
As I wrapped babe, there was a splosh noise, asked the student if it was the placenta - no the bed pan full of blood. But no further bleeding, mother turned on to semi recumbent, Syntometrine given (consented), placenta delivered by CCT (controlled cord traction) 2 mins later. 1000ml blood clot measured from bed pan, further 200 ml clot with placenta. No further bleeding, 2nd degree tear, not bleeding, left unsutured with consent.
Medical staff informed. IV access and hourly urine volumes and to recovery area to be watched carefully. mother feeling dizzy and light headed. No further bleeding. BP and Pulse satisfactory. Prior to going to ward further PV (per vagina) trickling of dark blood, fundus boggy and rubbed up, same again 20 mins later. Syntocinon infusion up and then to theatre for EUA (exploration under anaesthetic?) - nothing found. Further uneventful recovery.
I feel responsible for all thats happened - a beautiful birth resulting in so much trauma. Its the first time since qualifying that I had the opportunity, only saw 1 physiological 3rd stage in training. Got advice from experienced midwife prior to going ahead. Left well alone, didn't touch fundus. The mother had an average first and quick second stage, Hb was fine. Why did she bleed? Medical staff 'explained' that research (from this unit) showed there was 40% greater chance of PPH with physiological third stage management.
I feel put off doing another one!! Have probably put the student off too.
C - Midwife
I know how much you wanted to see a true physiological third stage and I'm so sorry things went wrong for the mum and you. What you described wasn't a physiological third stage though, even though it started out that way, as the mother was given Syntometrine and cord traction in the end.
It has been my experience with 7 of my own physiological third stages ( not a great control group I realise!) that I have always had a gush of clots prior to the placenta coming away, not 1000ml worth however, and as her placenta came two mins later I would hazard a guess her clots were from the same thing and the placenta would of presented itself very soon anyway. I would continue to have small gushes, mainly clots and not pumping/hosing blood, for the next few hours with my afterpain contractions.
Why did she bleed? Medical staff 'explained' that research .. showed there was 40% greater chance of PPH with physiological third stage management.
I couldn't say why this mum bleed, perhaps it was just bad luck, nothing in childbirth is guaranteed, but them throwing hospital stats around like that doesn't mean much; you need to know what their definition of 'physiological third stage management' is ( besides a contradiction in terms) and know the herstory of the woman cited in the stats birth ( herstory: what was her o/b herstory, her labour herstory and how the delivery went.)
Your support in helping her attain a physiological third stage was wonderful though, and again your skills in recognising things were abnormal following physiological third stage and intervening are what Midwifery is all about. Don't beat yourself up, pat yourself on the back!
I feel put off doing another one!! Have probably put the >student off too.
I'm sorry to hear that, don't be scared off, this has taken you out of your comfort zone that's all, and you can only grow from this.....meet the challenge :-)
Andrea, Mum of 9
I have an experiential theory that if 'fear' or 'cold' becomes a factor a the end of labour then a women is much more likely to bleed. To see a baby needing O2 and suction must be a real turn off for Oxytocin.
I think you are to be congratulated because, although in your mind you had planned with the woman for management without syntometrine, as soon as you recognised something was amiss, management was reviewed and totally appropriate action was taken. I would suggest that you try not to think of this as physiological gone wrong!!
Heather
I have experienced a few PPHs (interestingly mostly soon after qualifying as a midwife). So far, they have all been following administration of syntometrine - but I do not, therefore, feel put off from doing active management. What I am realising though, is that I feel increasingly more comfortable with physiological 3rd stages.
Lynn
The situation of a PPH is definitely one where it is good midwifery to have "your cautious expectancy skills ready to turn into life-saving action skills" well-honed. Well done C.
This is a little aside: Please don't let this put anyone off home birthing though.
If a PPH arises, then the midwife can do bi-manual compression and transfer in with paramedics as soon as possible, if bladder emptying and syntometrine intervention has not solved the initial bleeding.
(see 'emergency management of PPH in hospital or at home' for more suggestions)
In the home birth setting my experience is that most physiological 3rd stages are very straightforward and I believe less anxiety-inducing than injected oxyctocics with cct. I tend not to cut the cord until after the placenta is delivered unless requested to do otherwise.
Kerrianne
Dear C,
I hope you accept the reassurance you've been sent by other listwives - midwifery is all about recognising when Nature is going to play a nasty trick, and stepping in to thwart her, which you did!
I feel put off doing another one!!
I hope this feeling doesn't last, and the way to sort it is to read up as much as you can about physiological third stage - I mean the real stuff not the shroud-waving stuff.
Have probably put the student off too
And I suggest you and the student do this together, as she will also need to see that your care was exactly what the woman needed, supportive, watchful but active when required.
I'm a bit puzzled that you say the mother was "Still on hands and knees with bed pan beneath her bottom (but not sitting on it)". Perhaps this position prevented the placenta from separating cleanly?? Though earlier you say she was holding the baby?
Anyway, take heart - I'm sure she felt well cared for, and that's very important.
Ishbel
I'm really sorry you had such an unnerving experience with a 3rd stage, and thanks for sharing it with us, it reminds us never to cease our vigilence and to be prepared to help a labour at any stage. I totally agree with all Heather says about the likely causes and your excellent care.
I did a managed 3rd stage two weeks ago, and as it was the first managed 3rd stage I had done for about a year, I felt as nervous as many of you doing expectant 3rd stage. When I give the IM syntometrine, wait the 5 mins or so, then do controlled cord traction, I always feel very concerned until I have the placenta in the bowl and checked that it is all there.
Mary, midwife
I have arranged a home birth for my first baby. The midwife is supportive but is now telling me that it is the Trust policy that all home births receive the Syntometrine injection. I tend to be allergic to every form of medication, plus I want to keep this as natural as possible. Do you have any information/research on this injection - the Hospital argument is that I could bleed to death in 4 minutes and they don't want that responsibility - so that I can present an educated argument or find a compromise.
I suggest you get a copy of Nadine Edwards' book 'Delivering Your Placenta - the Third Stage' from the AIMS Publications Secretary, 2 Bacon Lane, Hayling Island, Hants, PO11 ODN. Cost £3.50 (including p & p - order form and details on the AIMS website.) It will give you all the ammunition to you need to back up your decision not to have syntometrine.
The Trust can have all the policies they like; they do not, and cannot, over-ride your decision. Sometimes, some midwives forget that they are professional ADVISERS and you can accept or reject their ADVICE.
Beverley Lawrence Beech
www.aims.org.uk
OK, first of all as you probably know, regardless of the Trust's 'policy', it is entirely up to you whether you accept any medication or intervention, and if they give it to you when you have refused consent then they will be in deep trouble! So when you have made your decision, if you still don't want syntometrine used for the third stage then make sure that this is written on your birth plan. I expect you know this, but want to avoid unnecessary aggravation and disagreements with your midwives - very sensible at this stage.
In your late stage of pregnancy, you might want to just avoid conflict and say 'yes' to whatever is suggested - then on the day, when in labour, you can state clearly that you 'do not consent' to syntometrine or any other drugs for third stage unless it looks like you really do need them. Saying 'I do not consent' is important - it carries legal weight and sounds authoritative! Your birth partner can make this clear for you too. Make sure it is established that you're not having it well before you actually give birth though, as some midwives give it routinely with the birth of the shoulders. Obviously this depends what you're comfortable with.
For more information on your rights, and guidance on getting what you want, and *expert* advice on how to handle conflicts, talk to Beverley Beech of AIMS. Her phone number is on the AIMS website at www.aims.org.uk under 'contact details' and she will not mind at all.
A number of trials have found that active management (syntometrine or syntocinon) reduces the rate of primary PPH, which is blood loss over 500ml. However, the same sources (eg the Hinchinbrooke trial, published in the Lancet) also tend to find that it makes no statistically significant difference to *serious* blood loss, ie over 1000mls. (This may be because the numbers of women having such serious blood loss is very small anyway - would need to look at the studies in more detail).
Loss of 500mls is not generally thought to be at all serious for a normal, healthy woman, but over 1000 mls may be. I understand that the WHO (World Health Organisation) has been arguing for a change in definition of PPH to loss over 1000 mls to reflect this, but do not have references to hand. From personal experience, I lost well over 500mls in my physiological third stage - 500mls landed in the jug, but there was plenty more elsewhere - and can honestly say that it was no problem at all. I was out shopping the next day and had normal Hb levels when tested 3 days later. So all that would really concern me personally is preventing major blood loss in the order of 1000 mls or over, and there is little evidence that active management will help with this.
In your position I would want my midwives/doctors to show me some evidence that syntometrine reduced my risk of 'bleeding to death in four minutes', as in these circumstances it is likely that prophylactic syntometrine wouldn't help at all!
I chose not to have syntometrine because of the increased risk of nausea, because it just seemed daft to have prophylactic drugs at the end of a drug-free labour, etc, etc.. to have it 'just in case' seemed to defeat the whole object! If you were to follow that to its logical conclusion, you would be in hospital having CEFM, an IV 'just in case' you needed one, and a cardiac team on standby 'just in case' you had a heart attack!
If it had looked like there was a problem, fine, I would have had syntometrine - many midwives find this perfectly reasonable - mine are all completely happy about it for this pregnancy too, despite my technically having had a PPH last time.
There is quite a lot in the National Birthday Trust Fund home birth study on blood loss, and as I recall this confirmed the general gist of things - ie you are less likely to have a PPH at home anyway as your labour is not interfered with, but if you are at home, syntometrine still slightly reduces the average blood loss - but does not seem to affect the rate of severe blood loss.
(See also articles listed below: links to other sources of information)
Is syntocinon only an option in the UK, rather than syntometrine? At least then she won't vomit! In Perth, we only ever use syntocinon routinely for third stage
Kirsten
In the units I've worked at in the UK, syntocinon is given (recommended) to women with pregnancy-induced hypertension - but it is not licensed for intramuscular use. So legally it is supposed to be prescribed on a named-patient basis, rather than by a midwife under standing orders. This is similar to the procedure for giving an unlicensed oral Vit. K. drug to a neonate, if you follow me! We do it, but the prescribing procedure is different than for other midwife-administered drugs. Of course, syntocinon is part of the syntometrine injection which we can give IM without an individual prescription and the drug books state that this portion of the injection is then administered via an unlicensed route! Meanwhile, no problem giving IV ergometrine - okay, under standing orders and fairly sure to make the mother vomit!
Carol
Am I the only person to be worried by the thought that if a midwife gives syntometrine at the presentation of the anterior shoulder she might find herself with a very serious problem should there be an undiagnosed twin lurking there?
Beverley Lawrence Beech
www.aims.org.uk
Erhm.. no, Beverley, which is why I never give it with the anterior shoulder - having seen exactly that happen when I was a student nurse.
Cate
Undiagnosed twins are extremely rare nowadays and a midwife, well this midwife, would not give with the anterior shoulder if there was any doubt.
Student devil's advocate here, but...
If there is not a researched based rationale for syntocin/oxytocin admin with the anterior shoulder, and there is a possibility, even remote, of negative outcome with undiagnosed twins- why is this done???
Sky in Ontario
Way back when I was a student midwife, we were always taught to give syntocinon (we don't use syntometrine routinely here) with the birth of the anterior shoulder, AFTER palpating for a second twin. But I don't think I've ever seen anyone do it.
Kirsten
I am not addressing active versus physiological management, but different ways of conducting a physiological third stage..
I was much influenced by a long discussion about third stages on sagesfemmes a long time ago. I believe much of what we understand to be true about physiological third stage in this country to be uneducated hearsay. In most normal cases, a placenta will detach from the wall of the uterus within ten minutes (whether you give an oxytocic or not.) Ultrasound studies show this. Sitting around for a couple of hours waiting for the thing to fall out after it has separated is dull, and can be dangerous.
What almost always happens, if you watch carefully and disregard the things you think you know about third stage, is this. The baby is born and the cord pulsates forcefully. The mother greets the baby and gives him or her her full attention. Within three to five minutes she will have a contraction and will usually look up and go 'ooh.' Within five to ten minutes she will have another, nasty contraction and go 'ow,' and whatever she is doing she'll normally shift around uncomfortably. This is because the placenta has hit her cervix. If you feel the cord, then, it may be pulsating, but the pulsation will be weak and thready. If she is in, or gets in an upright position, the placenta will normally plop out. Well within fifteen to twenty minutes.
If people want to wait forever, they're welcome to. But I think that is how the physiology works. And when women remain upright after birth, say kneeling, the placenta plops out in a very effortless fashion, none of the sitting around on buckets for hours that I was brought up with (which I think is what happens when you miss the vital signs of separation, the woman is lying or sitting, and the cervix starts to close...)
And, before I get a mass of abuse, I would just like to say that if I am your midwife and you have feelings about how you want your third staged managed, and want to wait for all pulsation to cease, or wait for an hour, or wait all day, or anything, I am happy to serve you in that choice. But if you're just somebody with no strong feelings about birth, and you just want to get your placenta out and get on with your life, and all your friends had 'the injection,' I'll tell you that in my experience, placentas normally come pretty quickly..
(ducking...)
Sara - midwife
Me,(trained before Synto) too Sara. I was taught to await the signs and symptoms of separation AND DESCENT and them facilitate the expulsion of the placenta.
Mary Cronk
Lisa
I do agree - I also tend to give the cord a little tension - note I said tension not traction - after that first contraction I feel the cord for pulsing I then hold the cord to a point of gentle tension - basically just straightening it out- this tends in my expereince to encourage the woman to naturally push the placenta out automatically when the 'ow' contraction comes. Most of the physiological thrid stages I have facilitated are all done and dusted in 20 minutes max. from birth time with little distruption to the woman and baby.
Amanda D - midwife
I'm with you on this one. I wouldn't be quiet so specific with timings and amount of contractions, but agree that most placentae are out within 30 mins or so.? As comparatively recent trainee of midwifery in this country (1990's) we were never taught properly about physiological 3rd stage.? I learnt the theory from American lay midwives, and the practise in independent practice.? I have independent now for 6 years - and in the first couple of years it wasn't unuasual for me to have 3rd stages of 1-3 hours!? Now, rarely beyond 35 mins.? I also will take up the tension of the cord, especially if the woman is by that time laying down, as many women wish to after birth, if it does not drop out when exiting a pool or whatever - and it was Mary who demonstrated the signs of separation and decent to me - so I feel privileged to have had such a teacher.
Lynn (midwife)
The Cochrane review of active management for third stage says physiological third stage takes an average of 9.7 minutes longer than active management.
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000007/frame.\ htmlI've seen a number of other references to placental separation occurring on average within 10 minutes in a phys. third stage, but delivery of the placenta taking longer. I suspect that more women would be interested in an expectant third stage if they were told it would 'cost' them 80mls of blood, on average, and 10 minutes; people frequently seem to expect it to take much longer.
There is a thread about length of physiological third stage on the
ob-gyn forum at
http://forums.obgyn.net/ob-gyn-l/OBGYNL.0606/index.html#842
some of
the US obs and midwives await spontaneous delivery of the placenta and
then routinely give an oxytocic afterwards. Several of them have
commented that they use gentle traction on the cord and third stage is
usually over in 5-10 minutes.
So do you reckon physiological third stages are unnecessarily prolonged when midwives who are only used to active management, don't really know what else to suggest other than 'sit and wait'?
Moving on to personal anecdote here - sorry - My 5 third stages have all been physiological. With the first, the midwives left me to it while they got on with the paperwork, weighing and measuring - I was told to push if I felt a contraction, but I didn't really feel any. It took about an hour and a quarter and there was lots of blood - big gushes of clots before the placenta; mw wasn't worried, and said that physiological third stages often took an hour. I really resented that time I was spending sitting there cold, shivering, and trying to do something boring. Did try feeding the baby but he wasn't that interested and I just wanted to get the third stage over with, so handed him over to his dad so I could concentrate. I felt very much left to get on with it, and I would have appreciated some guidance. With all the others, I've been on the ball and have usually had a cup of tea ASAP, then try to push the placenta out after the first one or two noticeable afterpains, and it has been over in 15 minutes or so each time. The big difference for me was knowing how to push the placenta; first time I was upright on a bidet, tried squatting, but I couldn't feel to push. Second time I discovered the wonderful trick of pushing as if for a bowel movement, and it has worked a treat. Have also heard from some members of the homebirth list that the privacy of the toilet helps them to deliver the placenta.
Angela - Mum and owner of www.homebirth.org.uk
This is from the Ob-gyn list:
Darryl.elrod @ LAKENHEATH.AF.MIL wrote: "If you call gentle downward traction physiologic, then sure. I don't have the patience to wait much longer than that."
I think this might be a British midwife:
"No, that's definitely not physiological. If you don't give an oxytocic then you must NOT clamp and cut the cord and you must NOT use any traction on the cord. You wait until the cord stops pulsating (for obvious reasons) then you apply the baby's clamp and cut leaving the cord unclamped. Then you use gravity and maternal effort to deliver the placenta. If you are deviating from this you are not doing either active or physiological 3rd stage."
I guess people love to have nice bossy fixed ideas about stuff, and our idea of third stage in this country has been very fixed. The way you describe your first birth - all that sitting around cold and lonely and bleeding - those were the kind of 'natural' third stages I saw when I was a student, and it is so obviously not natural, because so many women, like you, feel they have to hand off their baby to somebody else to get on with the serious business of getting the holy placenta out.
(I'm not knocking placentas - they're great - but surely you primarily get pregnant to have a baby, dontcha, not a placenta?)
Sara - midwife
I also feel that warmth of the woman helps with the physiology so I like to suggest the woman is wrapped in a blanket or two - cold and shivering without the babe in arms to me is against all the physiology
Amanda D - midwife
I've heard a lot of people say they are having a managed 3rd stage, so they can hold the baby etc. which is a bit backwards from my experience, I delivered both my babies on to my tummy, but first time there was then someone fussing around sorting the cord out and once that was done, DH was wanting to hold him, they wanted to weigh him etc. compared to a natural 3rd stage, where I got 20minutes of cuddles, then passed her to DH so I could squat and deliver the placenta, lovely!
Anne (mother)
Hi Sara
I have been reading your contribution with interest and found it thought-provoking.
I have been working independently for 7 ½ years now and must say that it isn't uncommon for the placenta to take an hour to emerge, usually with the woman sitting on the toilet and pushing it out if it hasn't fallen out through gravity earlier.
I attend a lot of water births and wonder that both because of the warm water and the lack of gravity everything takes a bit longer.
So far I have never had to take a woman to hospital for either PPH or retained placenta – it always feels like tempting fate to make statements like that...!
What I am trying to say is that the time factor doesn’t seem to have created a problem. I am definitely paying more attention to the woman being warm and cosy during 3rd stage. 3rd stages lasting much more than 1 hour often were due to a full bladder – but again no problem with excessive bleeding.
I think it is quite interesting that the time factor for 3rd stage seems so important to some women. I honestly can say I have only observed this very rarely if anything I need to remind the woman that it might be a good idea to part with the placenta! I wonder if the time factor is more important for everyone in hospital and that inadvertently the fact that it will take longer is emphasised and the women than think this is a bad thing.
In my opinion there are occasions when placentas can be encouraged to come more quickly but a longer 3rd stage in my experience hasn’t meant increased blood loss. Keeping the woman warm is important.
I remember a Tricia Anderson study day when she talked about what our ancestors did in the 'cave'. After a while they had to pee squatted and out came the placenta..
Elke (midwife)
"You wait until the cord stops pulsating (for obvious reasons) then you apply the baby's clamp and cut leaving the cord unclamped. Then you use gravity and maternal effort to deliver the placenta."
The course of action described for a physiological birth echoes that set out by Sally Inch all those years ago, and is very appropriate if the baby needs to be removed from the mother for any reason. But where the mother is able to remain warm and undisturbed just cuddling her baby, clamping the cord as soon as it has stopped pulsating is not truly physiological. Nature waits a while longer to naturally clamp the cord - a process that does not require plastic clamps or ties. I remember reading that the Maasai wait for about half an hour after the placenta is born before cutting the cord.
I guess that we don't really know what subtle things might be altered by artificial clamping before natural clamping has occurred, but in any case the clamping procedure, however adeptly and swiftly it is carried out, is an interaction with the mother that distracts her to some extent from her immediate responses to the baby, and also reinforces the impression that *things* have to be done to you by *experts* even during a very normal and straightforward birth.
..I am just suggesting we consider how the un-managed and undisturbed physiological process might proceed, and whether applying the baby's clamp may change this in some way or other that we are not yet aware of.
Alex - antenatal teacher
I think the placenta separates real quick and the body naturally does things to get rid of it, but if we miss those moments by waiting for the cord to go completely limp and empty, we make the birth of the placenta a far more complicated affair - do you see what I'm getting at. ..the placenta is often separated and ready to be born *before* the cord has stopped completely pulsating - but obviously after it has stopped really thumping...
Apart from the natural clamping, what benefits do you feel are derived from leaving the cord to pulsate when the placenta has detached from its blood supply?
Sara
We are trying to put together 'Best practice guidlines ' for 3rd stage . This includes physiological 'management'. I am comfortable and experienced with this, but many of my colleagues are not. The question that keeps coming up is "how long is it reasonable to wait for the placenta (in the abscence of excessive bleeding etc.) before we suggest /advice intervention? The arbitory 1 hour keeps popping up. Has anyone any suggestions /experience that may help settle this?"
We have no intention of permitting the medical establishment (through midwives) to dictate what will or won't be done to women's bodies ........... we will do our best anyway!! If it was left to them we would end up with "all mothers MUST have syntometrine" etc etc. This debate is a sharp reminder to me just how much control the medical profession still have in reality, and how midwives are used as tools of that control. Of course a woman has an absolute right to accept or refuse medical/professional advice. For some reason it still shocks me that 'professionals in power' can make 'policies'... which are basically rules....... that completely ignore a womans basic human right to exert control over her physical body. Absolute Bollocks !!!
Sue, Midwife
Surely it's upto the woman to decide how long to wait for her placenta. If she's made the decision not to have intervention in the third stage then why not let her decide when enough is enough. Most women have enough sense to realise they can't take it to Tesco - then again who are we to say????
Susie
The longest my senior midwife and I have waited for a placenta has been four hours. So long as there is no bleeding and one checks to see that the uterus is not filling up behind a detached placenta at the cervix, one can wait. Being a long way from medical help we must practice in the safest midwifery way. ie following the woman's body and nature. We cannot afford the consequences of "Meddlesome midwifery", that is to say medical management, so we do not meddle. Of course the fact that we could be prosecuted in our state for using oxytocics makes patience preferable. At the same time we must always have exemplary outcomes. It might be a good idea when trying to get back to the Heart of Midwifery, as opposed to obstetrics, to imagine yourself under this sort of constraint. Then ask yourself - how would you ensure good outcomes without the medical tools?
Angela C - midwife
Emergency management of haemorrhage at home births and in hospital
Grand multiparity and PPH risk
Implications of low haemoglobin levels/anaemia, including:Cutting the Cord - or not! - cutting, clamping, and lotus birth.
Association of Radical Midwives, discussions on evidence-based midwifery practice guidelines:
Jane Munro's paper
Dr John Stevenson's response
See also Staying in the water after birth? for discussion of Third Stage in birth pools.
Midwifery Today article on PPH
(www.midwiferytoday.com/Library/articles/hemorrhage.html
)
Midwifery Today E-news edition on PPH
http://midwiferytoday.com/E-News/enews1n35.htm
American Midwife Archives discussion of third stage issues
www.gentlebirth.org/archives/thirdstg.html
AIMS article on the third stage of labour
www.aims.org.uk/3rdstage.htm
Cochrane database summary of issues.
BMJ article - active management reduces blood loss
Letters discussing active management in the BMJ
The Lancet - full text of the Hinchinbrooke trial and correspondence
You will have to register (free) to use the Lancet first.
This article has an intelligent discussion of the
benefits of not clamping early when a baby needs resuscitation, and how cord
stripping can help with resus. It has lots of refs:
Cord Closure: Can Hasty Clamping Injure the Newborn?
By George M. Morley, MB., CH. B
July 1998, OBG Management
http://www.birthlove.com/pages/cords.html
AH updated 31 January 2001