Managing third stage?

**Cricket** · September 30th, 2007, 10:31 AM

I was discussing the managment of the third stage of labour (delivery of placenta) with a student midwife at my last appointment, and we were interrupted and didn't get to finish the conversation. But it raised some interesting questions in my mind. I hadn't thought a whole lot about it, really. From what I understand, active management has the midwife giving a shot of oxytocin at the delivery of baby's shoulders, and then waiting for the "separation bleed" of the placenta, after which the uterus is supported/massaged, and light traction is placed on the cord to encourage the placenta to come out. We didn't get to discuss the other option, but I am assuming that is to just let nature take it's course. I would have been inclined to go that way, however the student midwife said that active management reduces the risk of PPH by 50%. That sounds fairly substantial to me. My secondary midwife came in just after we had discussed active management and assumed that was what I had decided to do, which she said was much better, since you don't want to take the risk of PPH with a home birth.
(My secondary midwife annoys me. SHE doesn't want to take the risk. In fact, I don't think she really likes me having a home birth at all. And the idea of a water birth I know she dislikes. I am thankful to have someone else to work with most of the time, who is much more open to different ideas, while still informing me of the risks and benefits.)
What have you heard or read about the options? What is the risk of PPH to a normal healthy mother anyways? Are we talking 1% reduced to 0.5%, or 20% reduced to 10%? Are there other possibilities? I intend to discuss this further when my primary midwife gets back from vacation (Monday), but I would like to have some information to work with, so that I know some of the possibilities anyways. Thanks!

**BellyBelly** · September 30th, 2007, 10:45 AM

I think you're being led down the garden path personally. In a normal healthy birth, the risk of PPH is very low. Inductions increase your risk of bleeding as do instrumental deliveries.

Cord Blood - Why Delaying Cord Clamping Benefits Your Baby
Third Stage of Labour - Benefits of A Natural Approach

You can always say, 'my answer now is no, but if I have heavy bleeding I would be more than happy to have it.'

Also this is from Ina May Gaskin's The Farm, where there is no medical intervention at all:

Cases with no hemorrhage - 98.2%
Cases of postpartum hemorrhage - 1.8%

It's a completely different setting to hospitals but if you have a birth with no interference then I don't see it being high risk for bleeding unless you have a history of it...

**blue daisy** · September 30th, 2007, 11:51 AM

Hey Cricket

I second what Kelly has posted

It is important to remember that this is your birth experience, and maybe you need to remind your health care providers of this...

My secondary midwife annoys me. SHE doesn't want to take the risk. In fact, I don't think she really likes me having a home birth at all. And the idea of a water birth I know she dislikes. I am thankful to have someone else to work with most of the time, who is much more open to different ideas, while still informing me of the risks and benefits.)

it is a shame that you are feeling bullied...PPH is always at the back of a midwife's mind, but with a healthy pregnancy with no risk factors you are not asking too much to want a physiological 3rd stage

discuss how you are feeling with your midwives...dont wait until you are in labor

good luck

xx yogababy

**Cricket** · October 1st, 2007, 09:08 PM

Thanks so much ladies! The student and I were just about to discuss the "other" side when we were interrupted, so it's good to hear from you. I had a feeling it was something like that - that the risk was pretty low to start with, because I know I've read quite a number of birth stories with a physiological third stage, and no issues.
If I did have trouble with bleeding, would it be much less effective to begin treatment once the bleeding has started? Or is the outcome generally the same, whether you start bleeding and stop it with oxytocin, or have the oxytocin before the bleeding starts? (Does that make sense? My brain is not working so well these days, and what I want to say doesn't always come out so well on paper!

)
Thanks again!

**doulacara** · October 2nd, 2007, 04:53 PM

It seems odd to me that a homebirth midwife would be pushing a managed 3rd stage. I have had 1 managed which did not prevent a significant PPH leading to a blood transfusion. I have also had 2 physiological 3rd stages, and I had small bleeds with each, the second requiring oxytocin about a couple of hours after the birth - after the first feed. So yes, it can be effective to take a 'wait and see' approach.

**Cricket** · October 5th, 2007, 05:53 AM

Well, as I expected, my primary midwife is totally fine with a "wait and see" approach.

If labour is very prolonged, or very fast, she might recommend active management, but if all is well, we'll just let things be natural. She did say that I should be willing to accept the possibility of needing "interference" at that point, but that they would only do that if they felt it was necessary. Sounds good to me.

Come on baby!