Third Stage Management and your Birth Plan

By: Aunt Doula (10/24/2022)

One area of delivery that is often not spoken about or given much discussion is management of the third stage of labor - delivering the placenta. Often, most birthing people don't notice the delivery of their placenta or are only passively aware of it's occurrence, however this is a critical event and you have choices in how this stage is managed which can affect your postpartum healing and bleeding risks.

The placenta is approximately 10 inches in diameter - about the size of a dinner plate - and during pregnancy it is connected to your uterine wall with multiple blood vessels. After a normal vaginal delivery, the placenta should release itself from the uterine wall and be delivered about 30-60minutes after the baby.

The placenta leaves a dinner-plate-sized wound on the uterine wall that if not allowed to release itself properly can lead to catastrophic bleeding known as postpartum hemorrhage. The placenta requires time to cease blood flow through all the blood vessels it has built during pregnancy to properly and safely release itself from the uterine wall. If you will forgive the imagery, have you ever pulled a scab off a wound before it had time to heal? It bleeds because the blood vessels are torn open before new skin can protect them. If a placenta is forced off the uterine wall before it has completed its shutdown of all its blood vessels, the remaining wound will bleed significantly and dangerously.

If you do not elect a choice, you will be treated with "Active Management" of the third stage of labor. The alternative is known as "Expectant Management" and as their names imply, one is actively addressing and intervening regardless of a problem being present, whereas expectant management assumes there will be no problems and does not engage interventions unless a problem does present.

What does this mean for you? It can mean a significant difference in iatrogenic (doctor caused) complications that can affect both your immediate health and your long term recovery.

Active management is the "standard of care" in most hospitals, which means if you do not elect otherwise, you will receive active management which includes the following:

• Administration of uterotonic (contraction stimulating medication) as soon as baby is delivered
• The umbilical cord will be grasped and pulling traction applied to "speed up" the release of the placenta from the uterine wall - as you may have noted, this is in direct opposition to what was talked about above in regard to allowing the placenta time to shut down its multiple blood vessels. Umbilical cord traction is no longer recommended by the W.H.O.
• Fundal massage (the aggressive kneading of your uterus externally) Prophylactic or routine Fundal Massage is no longer recommended by the W.H.O.
• Early cord clamping of the baby (<60 seconds) Delayed cord clamping is becoming more common but it is not the standard of care or policy/practice of every provider

Some studies that were performed in the early 2000's indicated that active management was superior and should become the standard of care. Despite the studies being of low to medium quality and the repeatability inconsistent, active management became and has remained the standard of care for 20+ years. Despite an alarming amount of recent, repeatable evidence and studies that have proven active management is not better than expectant management, it remains. Active management has a number of negative side effects, most notably of which is an increased risk of postpartum hemorrhage after discharge from the hospital (late onset postpartum hemorrhage.) It also sets a very rigid time allowance for the delivery of the placenta to 30 minutes, and should the placenta not deliver, the standard of care is a manual (yes, by hand) removal of the placenta from the uterine wall by means of a doctor inserting their hand and forearm through the vagina into the uterus and scraping the placenta off the uterine wall with their fingers. This is done even in cases where there is no active bleeding and has also been known to be performed without anesthesia. These cases are not rare or edge scenarios - this is the "standard of care" for the roughly 4 million US births per year alone.

Expectant management is the application of time and allowance of the natural mechanism of the third stage of labor to take place. Expectant Management includes the allowance of:

• Delayed Cord Clamping (> 3 minutes)
• 30 - 60 minutes of time for the spontaneous delivery of the placenta to take place
• Allowing the birthing person to have the baby suckle at the breast to encourage natural uterotonic activity
• Allowing the birthing person to perform self fundal massage and taught how to check if it is needed.

Expectant management means less unnecessary medications with multiple negative side effects are administered. It means less pain and an increased sense of autonomy for the birthing person by allowing them to perform the fundal massage by themselves. It allows for the very beneficial action of delayed cord clamping which has numerous positive effects for the baby. Most importantly it allows the placenta the time it needs to finish it's final job and detach from the uterine wall appropriately and without extra injury.

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Much of hospital based births are subject to potentially unnecessary interventions in the name of "Standard of Care." It is therefore extremely important to understand where and when that standard was set, and for whom it truly serves. I believe strongly in the importance of fast response times, skilled surgeons and in the incredible care of NICU's - however applying 'too much too soon' in fear of 'too little too late' is not beneficial to every birthing person. The modern obstetrical intervention model of care applies monitoring instead of intuition and experience, pre-emptive treatment instead of watchful care with expectant management, and over reactive impulses rather than even keeled responses. All of this can quickly lead to the cascade of interventions, iatrogenic injury and traumatic birth experiences in the blink of an eye.

Selecting active or expectant management is a choice like any other on your birth plan, and comes with understanding what each entails. It is important to note that choosing expectant management does not preclude you from receiving any of the treatments that active management provides, it is simply choosing when those treatments are going to happen. Active management means they will occur regardless of a problem being present, expectant management says only to apply those treatments if a problem does arise. You will never be refused a life saving treatment for a complication in the third stage of labor because you chose expectant management on your birth plan.

The goal of choosing anything on your birth plan is that you are informed and educated on the choices available to you and are given a sense of empowerment to know what you expect to happen at each major event during your delivery. The third stage of labor and delivery is an important part of your birth journey, with lasting impacts after you leave the hospital. Ensuring you are well informed about this final stage of your delivery will hopefully give you a sense of complete control of your entire birthing journey and increase your sense of empowerment as you move forward into your official postpartum period.