The third stage of labor is the placental stage. It begins after the birth of the baby and ends with the birth of the placenta or afterbirth. It can be managed in one of two ways: expectantly or actively.
Expectant management means watchful waiting for signs of placental separation followed by delivery of the placenta through the mother’s pushing efforts. It may also include giving natural assistance to separation of the placenta by using nipple stimulation or taking advantage of gravity.
Active management is advocated by many physicians and some midwives and involves three steps:
- Giving medication to help the uterus contract before delivery of the placenta.
- Early cord clamping and cutting.
- Controlled traction of the umbilical cord for delivery of the placenta.
Research has shown active management to result in less blood loss and fewer episodes of postpartum hemorrhage for the mother. It is also associated with nausea and vomiting, and possibly high blood pressure. depending on the medication given to cause uterine contractions.
Even with expectant management, many practitioners will give oxytocin in the intravenous line or as an injection routinely following delivery of the placenta. This may cause unpleasant uterine contractions. Other physicians or midwives will use this medication only if there is excess bleeding, a soft(noncontracting) uterus, or a risk for postpartum hemorrhage. (Risks for postpartum hemorrhage include a very large baby or multiple pregnancy, very rapid labor, induction or augmentation of labor, or a history of postpartum hemorrhage.)
Cervical Inspection
Some physicians and midwives routinely inspect the cervix for bleeding after delivery. Others use this intervention only in the case of excessive bleeding that is not due to another cause, such as a noncontracted uterus or blood vessels torn in a lacerated area of the vagina or perineum. In this procedure, clamps are placed on the cervix, which is soft and easy to grab right after delivery. The cervix is pulled into the vagina and each area inspected for tears. Suturing may be called for if any tears are bleeding. Of course, the vagina and perineum always are inspected. This usually requires manipulation of the tissues. Blood will need to be wiped away and the tissues gently separated for better exposure. This can be uncomfortable, but generally is brief.
Manual Removal of the Placenta
It is done with the hands, using sterile technique. It is sometimes an emergency procedure if bleeding is heavy and the placenta cannot be delivered easily with traction and maternal pushing. It is also a procedure utilized by some practitioners after a set period of time if the placenta has not yet delivered. The time period before manual removal is utilized varies from institution to institution and practitioner to practitioner, but 30 minutes is an acceptable time to wait for placental separation without intervening. In out-of-hospital births, this time period is often stretched, if the woman is not bleeding excessively.
Uterine Exploration
The question of whether to check routinely for a nonsymptomatic uterine rupture after a VBAC is controversial. Usually such a rupture, called a dehiscence, requires no treatment and whether or not it is significant for a future vaginal delivery is not established. This intervention, then, is utilized with a good deal of variation among physicians and institutions. It is done after delivery by feeling the lower portion of the uterus through the vagina. The physician or midwife performing the inspection will wear long sterile gloves or regular sterile gloves and a sterile gown. This is an uncomfortable, but brief, procedure.