The final moments of labour are incredible.

Your body is working hard to bring your baby into the world.

The moment your baby is born, and you see, hear and touch her, you might be overwhelmed by any number of emotions.

Happiness, exhaustion, amazement and sheer relief might feature at any given moment.

Yet your body’s work isn’t quite complete.

After the birth of your baby comes the third stage of labour. This final stage begins when your baby is born. It ends when the placenta and membranes that have been nourishing and protecting your baby for nine months are expelled.

What Happens During The Third Stage Of Labour?

After your baby is completely born, your body will rest for a time. Usually, the third stage is the shortest part of labour, and lasts between five minutes and an hour. Contractions begin again, but they are usually much weaker than before.

These contractions encourage the placenta to sheer away from the uterus wall. The placenta and membranes will drop down to the cervix, which is still dilated after the birth of your baby.

You might feel the urge to push, as the placenta puts some pressure on your cervix. Pushing the placenta out can feel strange. It might feel like you have nothing to push ‘against’, so squatting or sitting in an upright position can help.

Your uterus contracts down, clamping the blood vessels at the site where the placenta has come away. This prevents excessive bleeding, known as a postpartum haemorrhage.

Once the placenta and membranes have been expelled, the third stage of labour is complete. Your care provider will examine the placenta and membranes to make sure nothing has been left inside your uterus. Your uterus will be palpated to ensure it is contracting down efficiently.

What Is A Managed Third Stage?

Most hospitals routinely manage the third stage of labour by giving an injection of artificial oxytocin about the time your baby’s shoulder emerges. This injection is usually given in the thigh, and it causes your uterus to contract very strongly.

Once your baby is born, the umbilical cord is clamped and cut, but you can request to leave the cord intact until it stops pulsating. Your care provider will place a hand on your abdomen to feel for the contractions, pushing down on your uterus while pulling on the cord to ease out the placenta.

The main reason given for a managed third stage is to ensure a speedy delivery of the placenta, and lower the chances of a postpartum haemorrhage. However it increases the risk of your needing medical attention, because of bleeding or infection due to fragments of placenta or membranes that might have been left behind in the uterus following a managed third stage.

In the past, the drugs used to stimulate contractions had side effects such as nausea and vomiting, high blood pressure, and strong pains. The single drug used today lessens the risk of these side effects but is less effective in preventing bleeding.

What Is A Natural Third Stage?

A natural third stage, also known as a physiological third stage, is when you rely on your own body’s production of oxytocin to expel the placenta and membranes.

During a natural, undisturbed labour your body has been producing continuous surges of oxytocin. This hormone cause your uterus to contract, which dilates the cervix and then pushes out your baby.

At the moment of birth, your body has one of the highest surges of oxytocin it will ever experience. This oxytocin signals to the brain that birth is almost complete and the next stage can begin.

Your uterus will contract very strongly once your baby is born. This sheers the placenta away from the wall of the uterus and clamps the blood vessels to prevent excessive bleeding.

Having skin to skin contact with your baby, and early breastfeeding will boost your oxytocin levels. This helps to contract your uterus and encourage the placenta to move down to your cervix.

Your care provider will be monitoring any vaginal blood loss during this stage, to ensure you are not bleeding excessively. You might be encouraged to sit, kneel or squat to help push the placenta out. It will be checked to make sure nothing has been retained and you are not bleeding too much.

Natural or Managed Third Stage?

The debate about which is better – natural or managed third stage – centres on the risk of postpartum haemorrhage (PPH).

A PPH is significant blood loss after birth – usually around 500mls or more of blood.

PPH is a rare event, occurring in about 1% of births, but it is the major cause of maternal death in high income countries.

In some situations, an actively managed third stage might be your only option. If you have been given artificial oxytocin to induce or speed up labour, your body hasn’t had a chance to make its own oxytocin. Having a forceps or vacuum assisted birth also increases your risk of excessive bleeding.

Research has shown PPH risk is increased in a hospital setting, compared with birth at home.

A study in the UK looked at women who received maternity care in preparation for a home or hospital birth. It excluded high-risk pregnancies, unplanned home births, pre-term births, elective c-sections and medical inductions.

The results of the study showed the risk of PPH greater than 1000ml of blood lost was about 2.5 times higher in women following hospital births, compared with women planning a home birth.

This research doesn’t necessarily mean hospital birth leads to PPH, or birthing at home will avoid it. What needs to be taken into consideration is the way women are labouring prior to the third stage.

In order to promote oxytocin, the hormone responsible for effective uterine contractions, birthing women need to have privacy and to feel safe. Hospital settings are rarely conducive to natural and undisturbed labour.

If, during labour, you have different care providers, the lights are on, and there is plenty of disturbance, all of this can have an impact on your body’s ability to release the placenta naturally.

Women who birth at home are more likely to choose that setting because it enhances their feeling of safety and privacy. Midwives who attend home births focus on pregnancy and birth as natural and normal processes.

Skin To Skin Immediately After Birth Helps Prevent PPH

Procedures following birth can also make a difference. Having skin to skin contact with your baby immediately following birth encourages early breastfeeding. Both increase the production of oxytocin and help the uterus to contract efficiently, reducing the risk of PPH.

The study looked at how the separation of mothers and babies immediately after birth affected the risk of excessive blood loss. It concluded women who didn’t have skin to skin and breastfeeding were nearly twice as likely to have a PPH, compared with women who had both within 30 minutes of birth.

The third stage of labour is often considered insignificant. For many women, however, the birth of the placenta is a very important moment. This is the moment you and your baby become separate, Honouring the placenta’s role can be very important.

Making the best decision about your birth place and carer can influence the third stage of labour. The less we interfere with low risk birth, the lower the risk of complications. But it’s important to remember medical assistance has its place, when needed.