Can we talk about the 4th stage?

[Jenne]

So, I watched a *very* activie 4th stage management including cord traction, cytotec suppositories, pitocin, *internal* uterine massage, several rigorous external uterine massages...

It was violent and hurt the mom worse than labor and delivery. It was awful. It was also at a hospital...although attended by a midwife...but she was in a hurry due to having multiple simultaneous deliveries...

Anyway, for those of you who have done this before or witnessed a birth before, what does a natural, unhurried 4th stage look like?

Does it always include rigorous external uterine massage? Internal massage? (I did provide vigorous nipple stimulation but this wasn't the first intervention...) Does a rapid explusion of the placenta increase the likelihood of hemorage? Traction? What is your 4th stage plan?

Jenne

[momma-molly]

I had a pretty active 4th stage with my DD. Cord traction, pitocin, external massage. I think I delivered the plancenta within 10 minutes or so after birth.

I specifically asked for no pitocin, but because I had an IV, they were able to start it without my knowledge (I know.). I reminded my doc about not wanted to have pit and the nurse piped up "Oh sorry, I already started it".

All of this stuff should have bothered me, but honestly? I was so enamored with my gorgeous baby girl that I hardly cared or noticed. Nothing they did was overtly painful. Certainly nothing compared to labor.

I've never heard of internal uterine massage - that sounds VERY painful!

My mom had two homebirths and I do remember the midwives doing external massage both times. With one birth my mom started to hemmorage and they did give her a shot of pit.

I'm curious to hear about what a natural 4th stage looks like too. Like I said, it was really not a big deal to me, but I'd like to be more in control this time and active manange my own care even after the baby is born.

[debra_lea]

I don't know. I have had 2 fairly fast labors. My first was 4 hours and my second was 21/2. With both of my speedy deliveries I bled quite a bit. I delivered in 2 different states with obviously 2 different homebirth midwives. For both they did some painful external massage (with both I remember thinking it was worse than the labor) and each gave me a couple shots of pitocin to get the bleeding under control. Honestly, I didn't care much. I would have preferred this option than having to be transported to the hospital.

If anyone has any other suggestions on what the midwives could have done, I would be curious to hear them.

[thankful85]

Wow - I don't remember any of that. I had two medicated hospital births - the most they did was push down on my stomach and that was with my second child. They didn't do anything extra with my first child - I delivered the placenta pretty quickly.

[mlec]

Hi, I'm not in your ddc (I'm due in Jan 2011) but I thought I would offer my experience. I'm expecting #4. #1 was a natural freestanding birth center birth w/ a certified nurse-midwife, and #2 and #3 were homebirths with a certified professional midwife.
4th stage, birth #1: after 30 hrs labor, 5 hrs pushing, the mw gave me a shot of pit once the babe was out, but I doubt I needed it. I was pretty tired but from what I remember, they helped me squat over a bowl about 10 min. after she was born and a beautiful large placenta plopped out. They did do uterine massge to help me clamp down (totally necessary in all cases, IMO), and it didn't feel good, but wasn't torture or anything.

4th stage, birth #2: dream birth after a quick 6 hr labor. Placenta detached and I wasn't bleeding, so she let me take my time. I credit my very little blood loss with drinking copious amounts of pregnancy tea through/o my pregnancy. Also, I tandem nursed right after the babe was born to help produce oxytocin. I got around to pushing out the placenta prob 20 min or more after the birth. Again, it was large, fully intact, and very little blood loss. And external uterine massage to help all those vessels clamp and stay clamped. She also showed my dh how to do it to make sure I stayed clamped down, but I don't remember it being necessary; I had light blood loss and a great recovery.

4th stage birth #3: very similar to #2. No problems.

I really think cord traction is dangerous. It can cause the uterus to clamp down and hold on to the placenta, or to pieces of it which cause hemhorraging and have to be manually removed (ouch!) or removed via d&c (ouch! + dangerous!).

[ashleybrook]

a natural 4th stage can look very different with baby going directly to breast which stimulates the passage of the placenta (by stimulating contractions of the uterus). and many times this is all that is required for the placenta to exit, bleeding to slow and life to move on. if baby isn't interested in the breast right away nipple stimulation is sometimes used as well as a natural alternative.
...very different way to handle the 4th stage. much more gentle, though it requires more patience, it's not unusual for the placenta to be out within 30 minutes-1hour after birth naturally... this is often assisted by standing up at the appropriate time, or coming into a squat to assist it's exit.
hope this gives you a different picture and option.

[Monkey Toes]

Wow, some of you had some intense experiences! My daughter was born in the water (after 8-9 hours of labor, 1.5 pushing?) and she came up to my chest and we relaxed in the tub. I offered her my breast but she wasn't all that interested. After a few minutes, 5-10 I'd guess, the cord stopped pulsing and they cut it. Maybe they did some external massage, but I honestly don't remember and it must have been mild. Having a baby in your arms is a powerful distraction I guess because I can't recall feeling anything. I didn't have an abnormal amount of blood loss, so I stayed in the water. At one point, maybe 20-25 minutes after birth, they gave a little tug on the cord and could tell it was loose. So my husband got out of the tub and dried off, then took the baby and sat with her. They helped me get out of the tub and onto a birth stool, where I gave one push and pushed out the placenta. I think I said something like 'enough of this. Let's be done' and gave it one hearty push. I'm sure gravity helped. Anyway, then we moved to the bed and snuggled again and I think they did some gentle massaging then just to make sure everything was shrinking down. Again though it must have been gentle, and I was distracted.

I don't think any of us did anything particularly 'right', but it is possible to have a gentle and smooth 4th stage. I hope it happens for all of us!

[debra_lea]

I breastfed right after my kids were born, and my big healthy placenta can out very quickly after delivery. However, I bled quite heavily and found the external massage very painful. I couldn't even hold my son the one time. But, I think it is fairly common to bled a lot when you had really fast deliveries??

[finnegansmom]

Um yikes! That's scary to read.
After my second, who had very sticky shoulders and needed O2 upon being born, was given back to me - still in the birth tub, I nursed him. I was supposed to have gotten out of the tub to deliver the placenta but I stayed in and delivered in there...It wasn't *right* away but it didn't take too long. There was no massaging or pitocin or cord pulling. Of course, after the glow of a the brtih wore off and i realized I was sitting in a fetid tub of my baby's poop, I need to get out ASAP... LOL.
I got onto the bed and my MW massged my uterus for about 10 seconds - she needed to make sure it was contracting and OK - it was. She may have done it again a little while later? Maybe not. It kind of sucked but so did the afterpains I had when I nursed my son for a few days.
I had a fairly quickly delivery, except for the shoulders, although I passed some ginormous clots later that day, of course being stubborn I was up and about making dinner 12 hours later so...

You should put your wishes for the 4th stage on your birth plan....they were on mine.

[Tresa]

I birthed my babies at a freestanding birth center...babies went to the breast nearly immediately after birth and my placentas came out soon after (time...? I have no idea, I was all high on birth hormones at the time). I do remember the external massage I got because I was bleeding heavily was as or more uncomfortable than my labor...maybe because there wasn't a productive end to it, maybe because it was just worse. Your stomach muscles are sore after the birth from all the work, and they mash and mold through those...it is very super uncomfortable. With my second, I let my midwife give me pitocin to avoid any more of that wretched massage. Which worked. Thank god for drugs, I was ready to punch her and the nurse to keep them away from me, I'd have rather bled out, seriously.

I think that hurrying the 4th stage comes mostly because of a hurried physician...you want to give your body a break before hurrying that placenta out before it's ready. I think your body needs time to recouperate before it has to clamp down and fix that big scar after pushing a baby out, and messing with it can cause problems just like any kind of interference with birth.

[bluebirdmama]

I've had two very different 4th stages. Both of my kids were born at home with the same team of midwives.

With my first, I nearly risked out of the homebirth for low platelets. They weren't drastically low like below 50 but definitely hovering around 90. For that reason we'd decided ahead of time to go with the shot of pit after the birth. I know some people say that the pit can help deliver the placenta more quickly but there are others who say that it causes the uterus to contract down too quickly and trap the placenta inside. I honestly don't know what I think about that. After the shot, I was admiring my son, he was at the breast but I can't remember if he was nursing or not. We waited for the cord to stop pulsing and cut it. I can't remember how much time went by before the midwives started getting worried that the placenta was not delivering. It felt like a while. At that point, the baby was passed to dh and I tried very hard to deliver that placenta because they were beginning to talk hospital transfer. The midwives were pressing faily hard on my uterus and I was bearing down as hard as I could. There was significant cord tranction including I think the midwife reaching inside me to try to pull it out. I don't know if that's internal massage or what. It was terribly painful. After 40 minutes we made the decision to transfer to hospital. I stood to walk to the ambulance and still no placenta. I remember getting a few afterpains in the ambulance but they were similar to the labor pains. During all the hubbub getting admitted to hospital and talking to the team there, still no placenta. I don't know how long all that took. I do remember a conversation about trying a further manual extraction at the hospital and my midwife assuring the team that we'd given it a huge effort at home. So they decided on general anesthetic and a D&C. The midwives were fairly nervous because of my low platelets. The placenta came out in bits and pieces and I lost about a litre of blood (not massive hemorrage but still sucked given my low platelets) so I ended up being pretty anemic postpartum. I have never quite been able to reconcile if something in the management caused the retained placenta or if I was just in the unlucky percentile of retained placenta statistics. Maybe all of that management was necessary and there was a chance that it could have been what it took to avoid the transfer. Maybe there was nothing we did that could have avoided the D&C. It certainly wasn't fun.

My second, I opted for the pit shot again (largely due to my history). We waited for the cord to stop pulsing and cut it. I was holding my daughter but she wasn't interested yet in nursing. I was having very strong afterpains. Placenta was delivered very easily with controlled cord traction (I didn't even notice this, but it is on my chart), but no external pressure after 10 minutes. I was extremely happy with this. I was dreading another retained placenta and hospital transfer and was very anxious to deliver the placenta.

This time I think I will delay the pit shot and only get it if it seems necessary and dependent on what my platelets do this pregnancy.

[ombrooklyn]

Wow, that was tough to read. Mine was SO simple. 12 hr labor, 15 mins pushing, born in the h2o at home, cord stopped pulsing then snip, about 10-15 mins after ds was born the placenta came out. He nursed after everything and that was that. I had no interventions, nothing. Took a shower, 3 motrin and laid in bed with my new baby nursing while DH made me a pb&j and our MW cleaned up.
I'm hoping this next one goes the same!

[Milly_P]

Wow, that does sound very traumatic! I had my last two babies at home and none of that happened. Painful but zero-intervention births, and afterwards just snuggling with hubby and baby, nursing, waiting to clamp cord until it stopped pulsing (very shortly after birth, actually), delivered placenta when it was ready to come, etc.

Even with my first, who was born in the hospital, there was very little "intervention". Just uterine massage (but I had an epidural so I'm sure they felt they could be rough 'cause I couldn't feel a thing).

Anyway, it should be normal that, just like the labor and delivery, unless there is a true medical emergency, there should be no need for intervention during any stage.

[homemademom]

With my first homebirth, I was bleeding more than normal and the placenta wasn't detaching. I passed pretty big clots and I believe my mw did a bit of gentle traction along with massaging my belly (which really hurt!).

My other two homebirths were uneventful. Baby born, nursed (or tried), cord cut after a while, placenta birthed and that was it.

For my one hospital birth, I'm pretty sure they gave me pit (because I was already on an IV), but the placenta came without a hitch, no excessive bleeding or anything.

[nia82]

Wow to the stories... My placenta came 3 minutes after DS followed by a gush of blood and they rammed a Pit shot into my thighs and were all panicky. They then started that uterine massage which is pure horror pain-wise. But I stopped bleeding rather quickly and lost under 600cc, so I think in hospitals they just get scared quickly.

[debra_lea]

I know I am commenting yet again, but i wanted to clarify that my placenta came out right after both of my deliveries. In fact, with my second, I delivered him in H20. After I stood to walk out of the tub, my placenta literally fell out! I seriously almost dropped the baby as he was obviously still attached and I was loopy on birth hormones.

But, like nia82, my intervention was just to control heavy bleeding. I only received the extremely painful external massage (my least fav part of birth) and a couple shots of pit to get my bleeding under control.

[OkiMom]

My two were a bit different from each other due to birth circumstances.
My first was born in a hospital. It was very unhurried, I was one of two women in labor at the time and I honestly think all the doctors/nurses were hiding in my room becuase the other lady was throwing things at them whenever they went into hers (she was right next door and I heard the abuse she was giving them i felt bad for them, one of the nurses had a cut from the book she threw at him). After the delievery I held her and nursed her for a while then they took her. Sometime in that time I was holding her I delievered the placenta, no tugging or pulling. They actually took the IV out before I was even stitched up (I tore really badly with both births).
Second I delievered unexpectedly at home. After 1 1/2 hours of labor and having my water break 5 minutes before her birth she came out with no pushing. When I got to the ER they started tugging at the cord and I yelled at htem to stop so they said that the L&D floor could deal with me. At the L&D floor the doctor called the ER doc something I won't repeat and basically told him he could have had me stand up and it would have fallen out (it was basically just sitting there, the doc in the ER was being dumb).

[hollytheteacher]

Mine was kind of a non event. After a long. long. long (did i mention long?) 37 hour labor with four hours of pushing (epi and pitocin on my back..etc.) the placenta part was easy peasy! She told me to push when i had the urge, i did, it came right out and that was that.

[Mrs.Music]

With DD I had the nurse from HELL who did my external massage. I swear she was trying to push my uterus out after the baby. With DS, my midwife (who was there in a doula-ish capacity) talked the OB out of ordering pitocin since I didn't want it and it obviously wasn't necessary. And the massage was shorter and lots less finger-tip stabby. But uncomfortable nonetheless. The afterpains with pumping were worse the second time around though. Anyway... I don't think it's supposed to be a big to do even in a hospital.

[pixiekisses]

Oh wow. America and their crazy interventions again.

I've never heard of cord traction before, or internal uterine massage, or external for that matter.
And there will be none of that at my birth, that's for sure. I'm gonna make sure to have that down in my birth plan just because I've read this. They might go "what?" but at least it's there.
And no meds, no pitocin or anything else. And they can't give it to me without my consent. I won't have an IV either.
Cord traction?! I'm still shocked here.