Third stage of labour
This article explains what happens in this part of labour and what your choices are regarding cord clamping.
After your baby has been born the placenta, which has sustained your baby throughout pregnancy, is no longer needed; you need to push it out along with the remaining part of the umbilical cord that runs between the placenta and your baby.
With no intervention the normal process is that your baby is born and you can greet and hold her while she remains attached to the umbilical cord. The cord supplies oxygenated blood which supports her until she starts to breathe on her own. The cord runs from her tummy to the placenta, which is still attached to the inside of your womb until the placenta detaches and you push it out.
You can ask for your baby to be passed to you or you may want to lift your baby up yourself. Some mums prefer to greet their baby by looking and touching before lifting her up and holding her close.
When your baby is born, the cord and placenta system will contain about one third of your baby’s blood, whilst the remaining two thirds is in the baby.
The cord at this point is thick, tight, rubbery and pulsating; pushing blood down the cord into your baby. After a few minutes the cord will stop pulsating. The mother will often feel an urge to push shortly after this and she pushes the placenta out or more often it slides out if she moves to a more upright position. The contractions may well be painful but the placenta usually slides out very easily and then the midwife will check it to ensure that it is complete and none is left inside the mother.
Delayed cord clamping is the process of waiting at least until it has stopped pulsating is also known as a physiological or natural third stage.
Many women prefer to have a natural third stage of labour and, particularly if they are planning a natural birth, see no reason to have drugs to help them with this stage. They want to be sure their baby has all the blood from the placenta because this makes sure the baby has good iron stores and enough blood to easily fill the vessels around the lungs making it easier for the baby to take a breath.
If the baby is attached to you via the cord she can't be taken away from you without your agreement. As long as your labour has progressed normally, your midwife should be happy to accommodate your wishes. Waiting until your body is ready to deliver the placenta can take a little time, from about 10 minutes to up to an hour (this might sound like a long time but you will have been saying hello to your baby so the time goes by very quickly).
Breastfeeding your baby as soon as she is ready can stimulate a contraction and help your placenta separate from your womb.
You are slightly more likely to have a heavier blood loss immediately after the birth with this method of delivering the placenta but if you are fit and healthy and have a good haemoglobin level (that's the iron level in your blood) that should not cause you any difficulty. Some women think that postnatal bleed stops sooner after a natural third stage.
There are varying levels of intervention that may be offered.
The cord may be clamped when it stops pulsating but before the placenta arrives. This may be done to allow the baby to be moved away from her mum.
It is common though for an active approach to be taken to the third stage of labour.
If you choose this way of managing your third stage of labour, your midwife will give you an injection of a drug (syntocinon or syntometrine) at the top of your thigh just as your baby is being born or soon afterwards. Most women will not notice the injection as they are too busy giving birth. The midwife will then clamp and cut the cord to stop the drug reaching your baby. The injection helps encourage a big contraction and means your placenta comes away from the wall of your womb quickly.
After a few minutes, the midwife will put her hand on your tummy to check that the placenta has come away and then she might encourage you to push the placenta out or she can just pull it out for you (this is called controlled cord traction). This might feel weird but not sore as the placenta is much smaller and softer than your baby.
Most hospitals still recommend this way of managing the third stage as there is a little evidence which suggests that you are less likely to have heavy blood loss immediately after the placenta has arrived. Some women think though that postnatal bleeding goes on longer after an active third stage but the choice is yours. Syntometrine has side effects which can include nausea, sickness and headache.
Cutting the cord early does mean that more blood is left in the placenta and less in your baby.
If you have had a more complicated birth and have needed a drip to speed up your labour or are having a forceps or ventouse delivery, your midwife will strongly recommend that you have an actively managed third stage as your risks of having a heavy blood loss increases if your labour is complicated.
If there are problems – for example, the cord is wrapped tightly around the baby’s neck – the cord may need to be cut straight away. In most cases, you can decide, with your midwife, how long you want to leave before the cord is cut. The cord is normally just long enough for you to hold your baby with the cord still attached to the baby and to the placenta which is still inside you.
Whether the cord is cut straight after the birth or when the flow of blood from the placenta to the baby slows down and stops before it is cut, the midwife will:
- clamp the umbilical cord about 3-4cm (1½-2 inches) from your baby’s navel (belly button) with a plastic clip and
- place another clamp at the other end of the cord, near the placenta.
The cord will then be cut between the two clamps, leaving a stump about 2-3cm (1-1½ inches) long on your baby’s belly button. Your midwife will cut the cord or ask if you or your birth partner want to do it.
There are no nerves in the cord, so cutting it isn’t painful for you or your baby. You can usually hold your baby while the cord is cut, assuming the cord is long enough to allow this.
Having your baby enclosed in your arms for the first time whether before or after the cord is cut is a memorable and important moment for you and your baby. As you cuddle skin-to-skin, both you and your baby have rising levels of oxytocin, the hormone that encourages affection, bonding and contentment. This hormone also helps you release milk when your baby breastfeeds and causes your uterus to contract. You may feel these contractions as a period-like or labour pain which is often stronger with second and later babies.
Your midwife will stay close until she is sure all is well. She may ask to examine your perineum to see if you need stitches, if the skin has torn.
The issue of blood loss may sound alarming, and in a small number of women, it is. However, for most women blood loss is normal and not a problem. During pregnancy your blood volume has increased significantly. So a healthy pregnant woman has a reasonable amount of blood to spare after birth.
For some women, there are health risks if they decide to have a natural, or physiological, third stage.
Women who cannot afford to lose even a moderate amount of blood in childbirth:
- women who are very anaemic, malnourished, unwell or weak
- women who have bled heavily during pregnancy.
Women who are already at greater risk of an above-average blood loss, for example:
- those having twins or very large babies,
- women with blood disorders,
- women who have previously had third-stage problems.
In these cases, medical management is usually recommended. But watchful waiting is an option, which is setting out to have a physiological third stage and switching to active management if blood loss looks significant.
If you are wondering how long you are likely to bleed after giving birth; it typically lasts from two to six weeks. See our article on blood loss after birth for more information.
Occasionally, the placenta does not come out easily even after the actions described above.
A ‘retained placenta’ means that all or part of the placenta or membranes are left behind in the uterus during the third stage of labour. You'll be treated for a retained placenta if the third stage takes longer than usual or if there are signs that any of the placenta or membrane is still attached to the uterus.
A retained placenta may be due to a small piece of placenta, connected to the main part of the placenta by a blood vessel, being left behind in the uterus. Sometimes a part of the placenta may adhere to a fibroid, or a scar from a previous caesarean section.
If the placenta still can't be removed, it may need to be removed by a surgeon. This is known as ‘manual extraction of the placenta’. You'll be given a regional anaesthetic such as a spinal or epidural, or you can ask for a general anaesthetic if you prefer. Before the placenta is removed your midwife will insert a catheter (a narrow tube which is passed into your bladder) to empty your bladder and you'll be given (IV) antibiotics into a vein (intravenously) to prevent infection. Afterwards, you may need more drugs which are given intravenously to help the uterus contract.
NCT's helpline offers practical and emotional support in all areas of pregnancy, birth and early parenthood: 0300 330 0700. We also offer antenatal courses which are a great way to find out more about birth, labour and life with a new baby.
Dads who are birth partners might find our online guides for them useful.
There is useful information in the NICE guidance on care in labour.
NHS choices also provides a guide to labour.