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Full disclosure this isn't my placenta, I didn't get a picture of mine, I regret it to this day!
The third stage (giving birth to your placenta).
Once your baby is born, the high levels of oxytocin (natural or artificial) cause your uterus to contract, and the strength of the contractions forces your placenta to detach from the uterine wall.
The contractions continue to shrink the uterus which seals off the blood vessels and prevents bleeding.
You might have heard that you have ' a dinner plate-sized wound' in your uterus. While it's true that your placenta is around that size, the wound size is quickly reduced by your shrinking uterus!
Active or physiological management is the third stage.
In the UK it is standard for an injection of oxytocin to be administered to facilitate the third stage, sometimes it is given with another drug called ergometrine (another drug that makes the uterus contract).
If you do not want this you need to opt out.
This drug is given as it is thought to reduce the incidence of a severe post-partum bleed.
A Cochrane review of the available evidence (in 2019) concluded:
'Although the data appeared to show that active management reduced the risk of severe primary PPH greater than 1000 mL at the time of birth, we are uncertain of this finding because of the very low‐quality evidence. Active management may reduce the incidence of maternal anaemia (Hb less than 9 g/dL) following birth, but harms such as postnatal hypertension, pain and return to the hospital due to bleeding were identified.'
However, some studies have shown that active management vs a physiological third stage (where your body is left to birth the placenta naturally) actually increases the risk of a severe bleed by 7-8 times and that it also increases the risk of postpartum depression (Lesley Dixion et al 2013).
In the physiological third stage, you choose to wait for your body to expel the placenta without assistance.
How long does it take the placenta to come out?
In active management oxytocin (+/- ergometrine) is administered immediately after the birth of the baby and before the cord is clamped and cut.
With active management, if the placenta isn't born within 30 minutes of the birth this will be diagnosed as a 'prolongues third stage'.
With physiological management, you are given 60 minutes before this is diagnosed.
Anecdotally though I have personally heard of stories where a placenta has taken anything from 15 minutes to 8 hrs in a physiological third stage (yes! The mum had a sleep and birthed the placenta when she woke!).
As long as the mum is not actively bleeding and there is no sign of infection, in physiological labor the placenta should be allowed to take its time, unfortunately with NHS midwives (especially in hospital), this time is interrupted with 'checks' and prompts to 'try to get it out'
For a physiological third stage, the mum needs to be truly uninterrupted as it is very easy to disrupt the hormone cascade.
This virtual doula's first retained placenta
The birth of my first was swept up into a cascade of interventions, which culminated in a prolonged period of coached pushing on my back, with the absence of any urge to push.
After my baby was born I was exhausted and happily accepted active management as they said it 'would be over quicker'.
In active management, the midwife periodically 'pulls' or to give it its medical name performs controlled traction on the cord, so for 30 minutes I had a midwife pulling on the cord periodically, but my placenta would not come.
After 30 minutes the midwife suggested that a Dr could come in and try to avoid theatre, I was given gas and air and a Dr tried to pull my placenta out, this was extremely painful.
It was then decided that I would need a manual removal in theatre.
I already had a cannula in, my husband was left holding a naked newborn baby that had been born 30 minutes earlier and I was taken to the operating theatre.
By this point, I was bleeding, and in a lot of pain as my uterus was trying to contract itself.
I was given a spinal anesthetic and a catheter was placed, my legs were put into stirrups, and the surgeon put his hand into my uterus and removed my placenta piece by piece.
I was diagnosed with a severe bleed after they reviewed the amount of blood I had lost in the theatre and on the way there.
It was also discovered I had a second-degree tear, which was stitched in theatre as well.
The worst thing about this entire situation was that I was taken away from my newborn baby, after an interrupted 30 minutes of skin-to-skin, and taken away from my partner who had been my support throughout pregnancy and birth.
I was alone, and although my midwife had come with me, she was preoccupied with calculating blood loss. The anesthetist was kind although at one point she asked 'why are you crying'.
This whole procedure was routine to them, they did it every day, but for me, it was one of the worst moments of my life, after a traumatic birth.
Placenta number 2 - spoiler retained again!
This time I had been warned I would need an active third stage due to my previous bleed (if only I knew then what I know now!). In reality, I had a choice, but it wasn't presented as such.
I also knew that I had a higher risk of a retained placenta having had one before, although I know now that my first birth had many contributing factors to a retained placenta such as a prolonged pushing stage (a tired uterus cannot expel a placenta very well!)
It's worth bearing in mind I was planning another hospital (birth center) birth, mainly because of the risk of needing to transfer for a bleed or a retained placenta, I wish now I had planned a homebirth, as that in itself reduces the risk of these things, but we don't know what we don't know.
This time I was much more prepared for my birth ( I wasn't a virtual doula yet though!) and my husband and I were able to advocate to such an extent that I had an amazing empowered birth.
I had put in my birth plan that should I need to go into theatre for any reason I wanted my baby and my partner to come with me, my midwife had told me this wouldn't be allowed, but I left it in my plan.
I accepted active management, but after the 30 minutes had passed, I opted to skip the Dr trying to pull my placenta out with only gas and air and go straight to the theatre. This meant I got an extra 30 mins or so skin-to-skin whilst they waited for a room.
I said I wanted my baby and husband to come, they accepted this, my husband went to get into scrubs whilst I had my spinal and I met him and my baby in the operating room.
The WHOLE vibe of the room was different (I know it could have been the different staff) but I felt like I was treated like a person rather than a number, I do think it was because my husband was there to witness my treatment.
It was still traumatic, but I was empowerd by my choice to skip the cord traction and to have my family with me.
What this Virtual Doula thinks everyone should consider in their birth-plan.
Active vs physiological management. Consider your environment in this choice, it's much harder to achieve a physiological third stage in a hospital where you are not in control of environmental interruptions and are much more 'on the clock', but it is possible with a strong advocate by your side.
Should you need to go to theatre for any reason (retained placenta, stitches), how do you want that to look, who do you want with you?
It is worth having some expressed colostrum available if possible. In my first birth when I was in theatre and whilst I was recovering my husband was unable to feed my daughter. The second time I had some colostrum in syringes so my son could be fed by my partner when I was in theatre and recovery. This took some pressure off me and also meant he wasn't trapped with a screaming starving baby.
References
Dixon L, Tracy SK, Guilliland K, Fletcher L, Hendry C, Pairman S. Outcomes of physiological and active third stage labour care amongst women in New Zealand. Midwifery. 2013 Jan;29(1):67-74. doi: 10.1016/j.midw.2011.11.003. Epub 2011 Dec 20. PMID: 22188999.
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