Third Stage of Labor

[anne1140]

I feel like I'm pretty educated in most areas of what to expect during labor, but I am currently reading about the third stage of labor and trying to decide what to include in my birth plan. Here are my questions for those who may already know more than I do on this topic:

Active management versus hands-off approach? Which would you choose and why? I know a lot will say hands-off, so I would especially like to hear from those who would choose active, but I definitely want to hear from both sides.

Can I have certain parts of active management and forego others? For instance, can I ask that the cord cutting be delayed, that they not push on my uterus and pull on the cord, but accept Pitocin? Can I delay the Pitocin until after the cord stops pulsating? Has anyone done something like what I am describing?

If you were at an increased risk of PPH (I am), would this change your mind at all? I have a blood-clotting disorder (vonWillebrands) and anemia. 

Thanks for any feedback!

[Smokering]

I opted for physiological third stage on my birth plan, but it wasn't really a biggie for me; and when the placenta wouldn't come out and the MW suggested a Pitocin shot, I was fine with it. (Didn't work, though. She eventually cut the cord and gave me another injection up through the cord, which was pretty neat, but didn't work either; turns out my cervix had clamped down over the placenta and it had to be extracted with forceps. So that was fun.)

I don't see any need to do it unless there's excessive bleeding or the placenta's taking a ridiculously long time to come out; but as far as interventions go, there are plenty I get more riled up about, you know? You might want to do some research on how/if it impacts natural oxytocin levels, though (dunno if it does, just thinking out loud!). My MW recently told me she prefers to do active management in the case of inductions, because having messed with the hormones to begin with, the natural process is less reliable and often needs a bit of help. I'd never heard that before.

And yes, I see no reason why you couldn't combine active third-stage management with delayed cord clamping. It's not like they have to give you the Pitocin shot at any particular time. It's what we did, although not deliberately... and nobody did any kind of abdominal massage, I'm happy to say! I'm not sure they do that here...

Of course, not having a needle jabbed into your leg is always nice, I feel... :p

[Lisoula]

I recently have had two patients with Von Willenbrands.  Both of them lost a LARGE amount of blood after birth, despite receiving a LOT of pitocin after the placenta was delivered.  I would have a long talk with your MW or doc now about their opinion on forgoing pitocin. 

[lunarlady]

If you are already high risk for PPH, I would definitely say avoid cord traction and go for the pictocin. Also, make sure you are doing things now to prep your body for third stage, taking your vit., supplements, teas, etc. It is shown that active management using pictocin does reduce PPH, and having suffered one, it is something I would definitely avoid. I would take pictocin, a lot of it, over a transfusion any day!

As for delayed cord cutting, that shouldn't be an issue. The cord usually stops within a couple minutes, and active management usually initiated 10 to 15 minutes after the birth.

Good luck with whatever you decide.

[msmiranda]

I have chosen physiological management for my birth because I want to avoid any unnecessary intervention.  However, I have two previous births under my belt where I bled very lightly and experienced no uterine atony, plus I have no other risk factors, so I believe I am at low risk for PPH assuming that this birth goes as smoothly and intervention-free as the others.  My doctor says they normally give the pitocin shot after the placenta comes out, and she normally uses some cord traction to get it out, which I am declining until at least 30 min has elapsed.  I am declining pitocin altogether unless heavy bleeding occurs and the uterus seems atonic.  She is fine with all of this but I have definitely been discussing it with her in detail and it will be in my computerized records if another doctor is on call.  Plus my doula and husband will be closely watching and helping me to remind the doctor of my wishes if I  need to.  It's interesting because I think the third stage stuff is something even many NCB mamas don't think of.  I don't recall it being covered in the Bradley class I took before my first birth or in any of the books I've read, and I never included anything on my birth plan about it before -- I was just lucky that both the midwife practices I delivered with did expectant management as their default. 

If I had risk factors for PPH, I might still want expectant management, depending on the setting I was giving birth in, but I would definitely talk it over with my care provider and do some of my own research to decide on the best course of action.

[JamieCatheryn]

The main problem in a some aspects of active management but not others approach is doing cord traction without pitocin, that really really increases risks and should not be done. For some care providers, normal procedure is to almost instantly cut the cord, inject the Pit and guide the placenta out physically, all within 2-5 minutes of birth, so if you want to take it slow but get the Pit, or whatever specific wishes, then talk with your care provider about exactly what you want.

My placentas come on their own in minutes, nothing done but a little push and cough on my part to get them out. Not much bleeding. I loved leaving the cord attached to the placenta for 45 minutes and not dealing with it until after moving to my bed and feeding the baby, it really felt unrushed and peaceful.