Third stage – after birth

Immediately at birth, the baby has been born but is still connected to you via the umbilical cord and the placenta and membranes are still inside your uterus. The cord continues to pulsate and deliver blood to the baby from you via the placenta, although the baby does not receive much oxygen via the cord now because it is using its lungs to breathe or cry. If left unclamped, the cord naturally continues to pulsate for a few minutes before it stops altogether. During this time the baby can receive up to 100mls of blood from the mother.

If all is well, the birth partner may be involved in clamping and cutting the cord, if they prefer. The cord is about 2 cm thick and around 50 cm long. It has two arteries and one vein inside but it does not contain nerves, so the baby will not feel the cord being cut. The cord is clamped in two places and the section between the clamps is cut to finally separate the baby from the mother. When cut, the cord feels slippery, gristly and jelly-like; similar to calamari. There may be a squirt of blood from the clamped section as it is being cut. Your midwife and/or obstetrician can provide guidance on how to do this safely. The baby may have already been handed to you and your birth partner immediately at birth for a cuddle or she/he may be handed to the Neonatal Team after cord clamping and cutting for examination and resuscitation, depending on circumstances.

An injection of an oxytocic medication (usually Syntocinon) is given to the mother into a muscle or IV once the baby (or babies) is born. This increases uterine contractions that separate the placenta from the uterine wall and cause the uterus to remain firmly contracted once the placenta and membranes are birthed.

The obstetrician or midwife will usually clamp and cut the baby’s cord within seconds or minutes. The birth partner can be involved in this process.

Once it is clear the placenta and membranes have separated from the uterus, the obstetrician or midwife will simultaneously place one hand on the mother’s abdomen just above the pelvic bone to brace her uterus whilst using the other hand to pull on the cord to birth the placenta and membranes. This counter pressure on the uterus and pulling on the cord is called controlled cord traction. The mother is not required to actively push during controlled cord traction.

Once the placenta and membranes have been birthed, the obstetrician or midwife will massage the mother’s abdomen to expel any blood clots and check her uterus is well contracted to prevent postpartum haemorrhage.

The placenta and membranes are then examined for completeness.

The other method of managing third stage allows placental separation and expulsion to occur spontaneously or by maternal effort. This is called physiological management. A Cochrane Review on active versus physiological management of the third stage concluded that routine active management is superior to physiological management in terms of blood loss, postpartum haemorrhage and other serious complications of the third stage of labour.

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During pregnancy, at full term, the uterus sits high up near the ribs. Following childbirth and complete birthing of the placenta and membranes, the uterus sits at or just below the level of the umbilicus (belly button). The uterus should be empty and the internal walls will have come together to compress the bleeding site where the placenta was attached internally. Additionally, the powerful uterine muscle fibres form natural ligatures that remain contracted to bind the bleeding blood vessels within the uterus and further prevent excessive blood loss from the placental site.

The most common cause of PPH is that the uterus does not remain contracted, as expected, after birth. This can be caused by prolonged or very rapid labour, augmented labour, as a result of a difficult birth or when the uterus has been stretched more than usual e.g. if you had twins, extra amniotic fluid around your baby or a large baby. A low lying placenta and adherent forms of placenta can also contribute to excessive bleeding. Rarely a tear in the uterine wall or inversion of the uterus can cause PPH. In these cases the uterine muscle has become compromised and it is unable to normally and effectively stay contracted to minimise bleeding. Other causes include cervical, perineal or vaginal tears that occur as the baby is being delivered and retained placenta or membranes (which is discussed below). A rare cause of PPH is that the mother may have a blood clotting disorder.

A PPH cannot always be anticipated or prevented. However, there are a few ways that the likelihood or severity of PPH can be minimised. Research tells us that the main way, as discussed above, is to use active management of the third stage to ensure the uterus is well contracted and blood loss is minimised. Other things that can be done include:

Your obstetrician and midwife will closely examine you and continue to routinely observe you following the birth. This involves checking that your uterus is well contracted, examining the birth canal for any tears, suturing any tears or episiotomy, and monitoring your vital signs (e.g. pulse, blood pressure, respiration). The placenta and membranes will also be examined for completeness. The blood loss at birth will be estimated. If you continue to bleed or if you show signs of compromise or shock due to blood loss, depending on the likely cause and amount of bleeding, the following actions may occur:

Once the PPH has been controlled your Maternity Team will continue to closely monitor your condition. Depending on your condition, and amount of blood loss, you may be initially cared for in the labour ward or intensive care unit (ICU).You may have more blood tests to see if your kidney function and blood clotting values are within normal ranges. Your vital signs and urine output (through a urinary catheter) and your vaginal bleeding will be closely monitored. If you had an operation your wound will be checked for any internal bleeding. You may be offered antibiotics to prevent or reduce the likelihood of infection. If a balloon was inserted into your uterus this is usually removed, through the vagina, the following day.

Following a severe PPH some mothers can be quite anaemic and very tired. Your midwives will care for you and assist you with your baby as required. The catheter in your bladder and the IV infusion will be removed once your condition improves. More information about PPH can be found in the resources section.