What you need to know about the third stage of labour

Like any stage of labour, the delivery of the placenta may not pan out as expected.
Like any stage of labour, the delivery of the placenta may not pan out as expected. Photo: sot

You did it! Your baby is safely out and in your arms and the relief is overwhelming. But unfortunately it's not over yet. Just when you think you're out the other side of childbirth, there's still more to come. And, like any stage of labour, it may not pan out as expected.

My first pregnancy was fairly problem-free. My daughter arrived naturally within a speedy two hours of labour. But I'd been so focused on the birth I hadn't given much thought to what happens next: delivering the placenta.

And for me, it didn't happen the way it was supposed to. The umbilical cord broke away and the placenta never came out, leaving me with what's known as a retained placenta.

Options for the third stage

Once you've given birth to your baby, it's time for the final part of labour, known as the third stage. This involves the delivery of the placenta and membranes (the afterbirth) and can be either physiological or active.

The most popular option is an active third stage: this involves giving the mother an injection of oxytocin as the baby's first shoulder is born, clamping and cutting the cord, then applying gentle controlled cord traction. The placenta starts to separate and is generally delivered in about six minutes.

Otherwise, there's the option of a physiological third stage; this occurs when the mother chooses to deliver the placenta naturally without the use of oxytocin. After the baby is born, it's a matter of waiting for the placenta to naturally separate, which can be encouraged by the mother breastfeeding her baby. Once the placenta separates and descends, the mother expels it while squatting, standing or gently bearing down. This can take anywhere from 10 minutes to an hour.

What happens next?

According to Gayle Green, midwifery unit manager at The Royal Hospital for Women, it's important to have the placenta delivered within 30 minutes after delivery, as "evidence shows that the risk of bleeding increases more dramatically after 30 minutes". 

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After this time, the midwife can take steps to assist the process, including putting the baby to the mother's breast to release natural oxytocin that may help the uterus to contract. The midwife will also ensure the mother's bladder is empty and that she's warm, in case of blood loss and going into shock. 

If the third stage is physiological, the mother may agree to have an oxytocic injection to help things along.

The retained placenta

A retained placenta is diagnosed when the placenta has not been expelled after 30 minutes of the delivery of the baby. It occurs in about 3.3 per cent of births.

According to Green, there are four main reasons for the occurrence of a retained placenta:

  • the uterus fails to contract and assist in the separation so the placenta remains adhered to the uterus wall
  • a trapped placenta, which is when a detached placenta is trapped behind a closed cervix
  • a small area of adherent placenta prevents the rest of the placenta from detaching, also known as partial accrete
  • the baby is pre-term (under 37 weeks). If the baby is less than 27 weeks, the chance of it happening increases dramatically.

When the placenta is a no-show

Once every effort has been made to deliver the placenta and it's simply not moving, the mother is taken to the operating theatre to it have it manually removed under local anesthetic - as I know all too well from personal experience.

After I was given a spinal block, my placenta was removed and all was well. But by the time I left recovery, I'd been away from my newborn baby for approximately two hours, which was distressing for a first-time mum. However, she was in good hands during that time (her father's), and mother and daughter were re-united as quickly as possible.

Will it happen again?

Once you've experienced a retained placenta, it may well re-occur during subsequent births. "If you've had a retained placenta and had it manually removed, you're looking at approximately a 17 per cent chance of it happening again," says Green - but of course your history would all be recorded and the staff would be well prepared.

I was certainly more prepared the second time around. Apart from having a cannula popped in my hand in case I needed a drip, I was also mentally prepared for what might unfold during the third stage. 

Had I known about retained placentas and the possibility of one occurring during my first birth, it may not have come as such a shock. We can't be ready for every possible outcome during birth, and a retained placenta is certainly not an everyday event. 

Fortunately the second time, it all went off without a hitch - placenta included.