Third Stage of Labor: Active vs. Physiological Management
The third stage of labor is considered the time between baby’s birth and placenta being expelled. Active management and physiological (also called expectant) management are the two approaches to this stage. What is the difference between these two approaches? What are the risks and benefits of each? What will be best for you? True informed consent means analyzing risks and benefits in the context of your medical history, and taking responsibility for that decision.
Active management of the third stage is a medically managed approach. Medication is given (ie – Pitocin) within one minute of birth. The umbilical cord is cut and cord traction (gently pulling on the cord) is applied to hasten the release of the placenta. After the placenta is expelled, the uterus is massaged. The American Congress of Obstetricians and Gynecologists considers active management of third stage to be the best practice standard of care.
There are risks to this approach. We know that 1/3 of a baby’s total blood volume is in the placenta at the time of birth. By immediately clamping and cutting the cord, baby is deprived of this blood. This means baby is starting life in a compromised state. Some medications used in this stage can cause nausea, vomiting, and high blood pressure. Be sure to ask your doctor what medication is being used and what the risks are of that particular medication. If medication is administered before the cord is cut, baby will be exposed. Another risk is that pulling on the cord increases the likelihood of partial detachment where some blood vessels are torn open but the placenta is still in the uterus so the uterus cannot clamp down to stop bleeding. Cord traction also contributes to placental fragmentation. It is also possible to completely detach the placenta prior to medication induced contractions which are needed to stop bleeding. Ironically, some of these risks lead to the very thing active management seeks to reduce – excessive blood loss.
Active management of labor aims to reduce total blood loss, length of third stage, and severe postpartum hemorrhage. Studies indicate these benefits more clearly in the hospital setting.
In a physiologically managed birth, the mother expels the placenta on her own. She waits for post-birth contractions and pushes gently. The umbilical cord is typically cut after it stops pulsing, which indicates that baby has received the full volume of blood.
The risk to this approach is increased chance of postpartum hemorrhage.
The benefits include full blood volume for baby, no risk of medication reaction, and no risk of manually separating the placenta.
It is important to note that if a physiological approach is taken and excessive bleeding does occur, there are measures that can be taken to reduce bleeding whether at home or in a hospital setting.
It is important to consider the place of birth when deciding which approach to take for third stage management. In a natural birth taking place in a home setting, natural oxytocin is plentiful. Dim lights, quiet and calm atmosphere, love and support all facilitate the release of natural oxytocin. The same natural oxytocin that causes contractions to birth the baby also causes contractions to release the placenta and stop bleeding. Natural hormone production is further stimulated thorough skin to skin contact between mother and baby, and nipple stimulation of baby suckling at the breast.
On the other hand, if labor was induced or augmented with synthetic oxytocin (ie – Pitocin) the production and release of natural hormones is altered. When used to induce or augment labor, Pitocin can overstimulate the uterus leaving it less effective at clamping down in the postpartum period (uterine atony). Saturating the oxytocin receptors with synthetic oxytocin can make the uterine response to natural oxytocin inadequate. Epidural anesthesia inhibits the natural production of oxytocin. These and other interventions in the natural birth process increase the risk of postpartum hemorrhage by disturbing the natural hormonal changes that take place in labor, birth, and the postpartum period. When natural oxytocin is inhibited, it might become necessary to use synthetic oxytocin to prevent hemorrhage.
Look at your own health history. What is your nutritional status? Ask your care provider about nutritional supplements (vitamins, minerals, herbs, etc) that might help reduce the risk of excessive bleeding in birth. Do you have a history of postpartum hemorrhage? Discuss this risk factor with your care provider.
There are risks and benefits to both active and physiological management of third stage. You must consider these risks and benefits, along with the context of this birth (interventions such as induction and augmentation, anesthesia, place of birth, etc) and your own health history when making a decision on the best approach for your birth.