Midwives - How do you handle the third stage and what are your reasons?

[JeanetteL]

Hi everyone,
I'm just wondering if anyone here can share their opinions/practices for third stage management (or lack thereof).

I've just learned that the midwife I used for my daughters birth normally does what I would consider somewhat active management (giving herbs within 20 minutes of birth and applying cord traction within 30).

It was my understanding that most homebirth midwives prefered a more natural third stage, letting things happen at their own pace and leaving the woman to deliver the placenta without intervention.

I'd love it if you could share your opinions and experiences with me.

Thanks

[applejuice]

That sounds like a time consideration for her not you.

My midwife always broke my water bag. I could handle any contraction with my posterior labors until she did that! After she did that, I was just out of my mind with pain and out of control. Now I understand that it simply cuts about an hour or so off of the labor, so that they get the show on the road and go home.

I understand this to a point. Why sit around for hours when you can finish things alot quicker by simply breaking the bag. But then that is why I chose a home birth - to labor and deliver with as few interventions as is possible.

The third stage was managed aggressively for the first baby, but with the second, third, and fourth, I guess she let nature take its course, but I delivered without any interventions ( that I know of). She did use some herbs on my abdomen during the 3rd birth during 2nd stage to help facilitate the management and progress of the 3rd stage. (some aromatherapy or something.)

I guess I am lucky. I never had any IV's, episiotomies, drugs, monitors, pitocin, etc., so I guess I should be grateful. I could also eat and drink throughout labor and then puke, pee, and poop as much as I needed, and walk around. I could assume any position I needed to push, so I guess I had the very best I could have as far as birthing is concerned in the twentieth century.

[pamamidwife]

I encourage my clients to birth upright, so moms are usually on their knees or sitting after the birth. Unless there is bleeding, I don't hurry the placenta. The longest I've waited is two hours - and only did measures to facilitate the delivery because there was a partial separation after an hour and a half (with blood loss - a uterus cannot contract with a partially separated placenta).

What I do notice, however, is that right after the birth, there is this sincere connection between mom and baby. Only when she takes her focus off the baby do I assume the placenta has separated. Usually, she'll comment about some cramps. In an upright position, no cord traction is needed. Sometimes, on the back, it helps a bit, but it's rare that it's needed.

If membranes are still hanging on with the birth of the placenta, I ask mom to cough while I turn the placenta over and over slowly, not tugging on the membranes. This prevents tearing and leaving a portion of the membranes inside the uterus.

[marymom]

pama, did you say membranes still in after placenta is delivered? How does that happen?
by the way, love your site/diary...

[pamamidwife]

Originally posted by marymom
pama, did you say membranes still in after placenta is delivered? How does that happen?

Sometimes the membranes trail behind the birth of the placenta. Sometimes they slip right out, and other times, depending upon the length, they may hesitate a bit in the cervical os, or in the vagina. I don't pull, because they easily tear away - and any small amount of anything can cause heavier bleeding. So, I usually just have the mom cough while I turn the placenta over and over in my hands, gently coaxing the membranes out.

Does that make sense?

Oh, and thanks for the compliments on my journal. I love keeping it!

[lorijds]

Well, since not many have posted, I will add what is done in our birth center.

We will usually wait an hour. During the time we are waiting, we encourage the mom to put the babe to the breast, as that usually helps with the detachment. Position changes usually help, too, especially if mom is in a lying down position (and while our clients assume any position they want, many end up on their side for births. Even if they birth in an upright or hands and knees position, many choose to recline after the babe is born). If it is longer than an hour, it depends upon the situation...bleeding, the practitioner's gut feeling, the mom and how she feels about it. But usually at that point the midwife will go in after it, or at least explore to see what is going on (is it hung up, etc).

I would like to point out that there is a difference between traction and really pulling to detach it. Sometimes it is hard to tell if it is detached or not. If you put a clamp on the cord and pull downward, you can feel if there is give, where maybe the placenta is hung up on the pubic bone or something. If there is no give, they should leave it alone. Pulling hard enough to detach it if it is not yet detached just puts the mom at all kinds of risk, in my opinion.

From my observation, the vast majority of placentas usually come anywhere from 5 minutes to 30 minutes after the babe, with only help from the babe's nursing. No other management is usually needed (and that is how it should be, in my humble opinion---the babe initiates the process, and completes the process).

[Carolinamidwife]

What I do notice, however, is that right after the birth, there is this sincere connection between mom and baby. Only when she takes her focus off the baby do I assume the placenta has separated.

I was going to say that I notice this same exact thing. All of the midwives I have attended births with perform gentle cord traction to help assist placental delivery after there has been separation. We are all acutely aware of the main reason for third stage hemorrhage so no one diddles around too much. I, personally, hope to have my clients squat but I have yet to see a client who was willing to get back up after she has laid down! The first time I delivered a placenta I was extremely nervous and certain I was about to rip the cord off so my personal philosphy will probably be very hands off. Right now I do it however the midwife I am attending with does it. The last placental delivery I managed I waited too long after separation (because I did not see any signs) and the mom developed some massive clots behind the placenta and was in a fair amount of pain. She was supine and I feel that if she had been squatting she would have felt the placenta drop into the vault and had the urge to expel it. You live you learn.

[cottonwood]

Have any of you seen evidence of a connection between cutting the cord and abnormal detachment of the placenta? I'm trying to think logically why that might be, but don't know enough about the chemistry of the process to figure it out.

"I, personally, hope to have my clients squat but I have yet to see a client who was willing to get back up after she has laid down!"

In my case, this was because psychologically I had given the birth over to the midwife -- I was exhausted from being micromanaged every step of the way, so she could damn well take care of the placenta too! lol. But really, it felt very very anti-climactic, and I felt very put upon to have to do more work after I'd just birthed the baby. I was on reclining, so I had to push *hard* to get it out while they applied cord traction. If I'd been told that with squatting there would be little or no more hard pushing from me, you bet I would have made the effort to get upright.

With my second birth, I was still of the mindset that "I've done all the work, I'll relax, now the midwife can take care of the rest." I really hadn't educated myself about third stage at all. So it was just sheer luck that after an hour with no placenta (and a nervous midwife, despite the fact that I felt GREAT) the midwife's assistant suggested that I squat. I had to get up to go pee eventually anyway, so at that point it was really not all that big a deal. And voila!, the placenta slid right out.

My third was unassisted so there was no feeling like somebody else ought to be taking care of this or that for me. I waited about half an hour (felt great, again, so was really not concerned) then handed the baby to my husband and got up on my haunches. I waited a few minutes, then had that same urge to push that one has when having a bowel movement, and again it slid right out. I'm a big, big fan of squatting, obviously.

I think, in dealing with clients who do not seem to want to get up after the birth that a few things might help. First, explain to her before the birth how much easier squatting makes the expulsion. Second, if the mother has not actually given birth in bed, have her rest on a couch or recliner instead of going to bed immediately after the birth. It is much easier to maneuver into a squat position from either than it is from a nice little cozy nest in bed. Third, leave her completely alone after the birth so that she has a chance to go through that stage that Pam spoke of, where she is connecting to her infant. If she is allowed to go FULLY through that, with no pressure to cut if off prematurely, it's likely that at some point she will wish to be physically seperated from the baby via the cord (assuming it has not been cut yet) and will of her own accord set about figuring out a way to facilitate that -- that might be the best time to ask her if she needs help squatting.

[lorijds]

Those are good points, blueviolet. More education prenatally, like in childbirth classes and at appointments.

My one thought is, usually our clients are reclining and nursing when the placenta separates. This is why most of them don't get up and squat, because of the physical and emotional fatigue, as well as the fact that they got the babe latched on, which is easier for some babes than for others.

I can't see us leaving someone alone completely when the placenta has not yet been birthed. In the event that it only partially detached, and the mom hemorrhaged, she could bleed out over 1000 ccs before someone would notice and yell for us. I think, liability wise, that isn't going to happen. You are right, though, there *is* this moment where mom kind of gets far away. While we can't completely leave women alone, we can stop fiddling with them, keeping the interventions to a minimum. It is kind of interesting that we talk about natural childbirth, sit on our hands and try to be mainly supportive...and then kick into gear after the baby is born. It helps me to remind our clients that the birth isn't over yet, so don't get on the phone, calling people and celebrating....just enjoy these first moments with your child, get to know each other. It is also a reminder to us caregivers, to sit back and relax a little, let the family have their time without interfering.

I will keep your comments in mind, though, when I am teaching chilbirth classes or I am at a birth where the placenta isn't coming smooth and easily.

Lori

[thebabycatcher]

I am probably going to be in the minority here but I like my placentas out very quickly.
Placentas generally detach within 5-10 minutes after birth.
I am paying close attention to mom and when I see a "seperation gush" I will ask her if she is feeling any cramps. Usually she is and I will guide the placenta out- sometimes with controlled traction, sometimes not.
The reason I like my placenta's out quickly is that it prevents excessive blood loss. Plus my moms are SO relieved to have the placenta out and be done.
My senior midwife trained me to do placentas this way and I have enormous respect for her.
Many of the homebirth midwives that I know want their placenta's out quickly.
Some midwives wait until the cord has stopped pulsing to deliver the placenta. I don't do this because the cord is pulsing with the babies heart beat, AFTER the placenta has detached. Meaning the baby isn't getting any more oxygenated blood because the placenta is no longer functioning.
I never cut the cord until the placenta is out, by the way.

[pamamidwife]

If true separation has occurred, then there's no reason why the placenta should get hung up or stay in the uterus. Usually, the uterus will start to contract, mom will notice and encouragement to squat or move a bit to birth the placenta is easy.

I don't see the separation signs always happening within 5-10 minutes. I just don't. Typically, in my practice, it's about 20 minutes or so. I'm not sure if this is because of the time that women are allowed to just be with their babies, but I don't see an increased amount of blood loss or hemorrhage.

If the placenta isn't separated at all, there's no hurry to rush third stage. In doing so, more problems might be created. However, if there are true signs of separation or even partial separation, getting the placenta birthed will alleviate any risk of clots forming or more blood loss.

Whether or not the cord is pulsing is irrelevant as to when you "should" deliver the placenta. In my eyes, it's not up to the attendant so much, but the body will birth the placenta as it should. I'm not talking about situations with partial separations - which are dangerous and create catastrophes, as Lori mentioned, rather quickly. I usually cut the cord after the placenta has been born.

It's very different, too, if the placenta HAS separated and is just sitting in the os, with a fountain of blood clots behind it.

One doesn't have to be wholly active for third stage to be safe. Just have a keen eye and notice the small things...

[thebabycatcher]

Sometimes, after seperation, the placenta does get hung up.
Particularly if it is coming Duncan, or maternal side, first. But sometimes there is no apparent reason why it doesn't come. And when they are just sitting there like that, a lot of blood/clots can build up behind them. If a placenta is taking a long time to come, I will sometimes place a hand on the fundus to be sure it isn't rising.
And my moms get plenty of time to just be with their baby. Immediately after the baby is born it goes up on mom. If anything needs to be done to the baby, it is done directly on her and then I leave them alone.
I sit quietly near by, and begin watching for signs of seperation ( cord lengthening, seperation gush, etc) The mom is usually completely oblivious to anything I am doing.
When I see the signs, and mom is feeling cramps, we get the placenta out. It is very simple and again, my moms really appreciate getting the placenta out and are ready to snuggle into bed.
I certainly don't feel like I am intrusive or over managing. And my clients don't feel that way either.

[phoebekate]

I am not a midwife, just a mum of one who found this discussion interesting, particularly the idea that it is difficult to get mum's to squat for the placenta to come. I had about 3 days of prelabour then a 5 hour active labour following SROM, laboured completely intervetion free (inc no internals) and delivered DD in a standing squat supported by DH. My midwife caught DD from behind me and passed her through my legs and then I sat down (lounged on a bean bag) and held her skin to skin. After 10 mins my midwife asked me if I thought I could squat to see if the placenta would come, so I did and out it plopped (she obviously had seen signs that this would happen). She popped it in a bowl for a while but the cord was quite short making it rather hard for me to nurse DD without threatening to pull the bowl all over us both, so we cut the cord quite soon. I was tired I suppose but mostly I was elated and amazed and far too high on my own hormones to notice how tired or sore I was yet. It was a great time to ask me to squat because I was entirely agreeable!! I think it would have been quite disrespectful and also sad for me in retrospect to have such a great birth experience and then have my midwife "manage" the 3rd stage unless there was any sign of trouble.

We had had many discussions with our midwife to the effect that we would of course have syntocin if I was bleeding too much or it was taking too long (defined as 1hr plus on paper but anywhere between 1/2 hour to 2 hours verbally depending on the birth and circumstances at the time). If a more managed approach had been called for so be it, but I would have resented being rushed along 10 mins after the birth if it hadn't happened on its own by then.

[marymom]

I am curious,
If mom is laboring with few contractions,
yet dilating still, albeit slowly but surely,
is that an indication of potential bleeding in third stage? If so is there any thing you midwives do preventatively (besides having pit/or methergine on hand)

[JuicyPakwan]

I am a CPM but have not started practise so all my experince is from 50 odd births from apprenticeship. I only saw 3 really bad bleed out of the lot and 2 where from the same mom different babies. Her placenta came out in pieces both time ended up in hospital but no transfusion. The other was a slow steady bleeder also ended up in hospital. Both women it was kind of expected. The midwife I apprenticed with was very hands off unless required. My question is about my second birth. My first was 24 hrs but basically no bleeding very clean birth. My second was only 12 hrs and labor was fantastic. Pushing was horrible but only lasted 9min I felt like she was ripping out my bladder with her. My pubic bone also seperated I found out by walking later. She was only 8lbs. I delivered on my side. I delivered the placenta six minutes later still on my side with about 4 cups of blood with it. I didnt' bleed hardly at all after that. I didn't go to the hospital for another six hours when it became aparent I couldn't go potty or even sit up without fainting. I just got a cath and IV and went home in much better shape. Why did I bleed was is the position the difficult pushing? I forgot to mention I had shoulder dystocia the midwife went in past her wrist to get her out but I did not tear. Which makes me think the shoulder dystocia wasn't a space problem does that make sense? After such a fantatic labor I was shocked and angry that my body pooped out like that ,there was no cord traction she didn't touch my uterus. I fell apart emotionally before the placenta came couldn't stop crying the pushing hurt sooo bad. I will be having my next baby at home and am not afraid I just want a good answer to why this happened. I'm also planning to birth upright and catch my own baby. We will be having a midwife as my husband does not feel comfortable with a UC considering the complications last time. It has taken me a long time to reconsile this with the fact that I'm a midwife and was transported that kills me. Maybe I needed a lesson in humility. Sorry this is so long.
Emily

[marymom]

heyyyy Emily, shoulder dystocias are rough for mommies, My last baby has an injury from a dystocia,( at home)
I dont know what your baby was presenting with, Mine was a brow and he was larger, and his shoulder got stuck under neath the pubic bone, not sure if this helps, email me if you want,
I have some pretty opinionated(but flexible) views on dystocia management... I do believe my son's injury was a great learning lessn for me...

Maybe the bleeding was due to the enlarged bladder, maybe the bladder didnt want to do anything after the trauma?
Ive just done a few homebirths (of others) a few hospital births,(maybe 20?) as a doula, hope to be working towards my CPM soon
I think my preceptor is working on the papaerwork
maybe next hypothetical questyion coiuld be on dystocia