Stage 3 of Labour
The third stage of labour is the delivery of the placenta, which is expelled by contractions of the uterus. There are two ways of managing this stage: naturally (physiologically) or with an injection (actively). You should be given the opportunity to discuss the options beforehand, or put it in your birth plan, but how it is managed will depend partly on the nature of the birth.
Women who have given birth naturally, with no intervention, often want to complete the process naturally, without drugs. Once the baby is born, the cord is left attached until it has stopped pulsating, when it is clamped and cut. The uterus will contract naturally, but it can take longer to expel the placenta. Blood loss tends to be heavier but this is seldom a problem as long as the mother is healthy and not anaemic.
It is perfectly normal to get the shakes after the delivery of the placenta. Your legs may feel wobbly as a result of change in body temperature and loss of fluid, as well as the sheer effort of childbirth. All being well, you will now be given a chance to spend some special time with your baby, so that you can get to know each other, before she is checked over.
Immediately after the birth, the midwife will inject an oxytocic drug (ergometrine plus oxytocin) into your thigh. This is a synthetic hormone that causes the uterus to contract and the placenta to detach from the wall of the uterus. You will feel a contraction and the midwife will place one hand on your stomach while she gently pulls on the cord with the other hand. The blood loss tends to be lighter using this method, although the drug can make some women vomit. The ergometrine can cause a rise in blood pressure, so, if you have high blood pressure, you will be given an alternative drug, oxytocin, intravenously. If you had an intervention during labour, for example, an induction, epidural, or an instrumental delivery, and are at higher risk of bleeding, it is advisable for the third stage to be actively managed.
The midwife will check the placenta to make sure that it is complete. Occasionally the placenta fails to separate from the wall of the uterus, or does so only partially, and a small amount of placenta left in the uterus can result in heavy bleeding and infection.
If various efforts to expel the placenta, for example, putting the baby to the breast and encouraging the mother to empty her bladder, have failed it will have to be removed manually in an operating theatre. This procedure is undertaken under spinal anaesthetic and the mother would be given a course of antibiotics afterwards in order to reduce the risk of infection.
After the delivery of the placenta, the midwife will check your vagina and perineum for any tears or grazes. A small tear that is not bleeding will heal naturally if kept clean and dry. A cut or a larger tear that involves muscle as well as skin will need stitching soon after the birth. You will be given a local anaesthetic in the area before the stitches are put in. The stitches do not need to be removed because they will dissolve. If you have had an assisted delivery, the doctor will stitch the cut as soon as the placenta is out and while your legs are still raised.
In hospital, your legs will be placed in stirrups with your feet higher than your hips. You will be injected with a local anaesthetic a few minutes before the stitching begins. The muscle is aligned and stitched first and then the skin. You may be able to use gas and air while you are being stitched, although the local anaesthetic should provide enough pain relief. If the stitching is still painful, ask the midwife or doctor to stop until you are comfortable with the pain relief. The procedure usually takes about 20 minutes. At a home birth, the midwife will probably ask you to sit on the edge of the sofa or bed while she inserts the stitches.