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The Third Stage of Labour

Choosing between Active and Physiological Delivery of the Placenta

Whether you plan to give birth at home or in hospital, you can choose to have drugs to help you deliver the placenta, or to go for a 'natural' third stage.

Active Management - drugs for third stage

'Active management', or a 'managed third stage', means that you have an injection as the baby is born, or shortly afterwards, which makes your uterus contract strongly to push out the placenta quickly, and then makes it clamp down tight to reduce bleeding after the placenta is delivered. In the UK, the drug most often used is Syntometrine - a combination of Syntocinon, to bring on strong contractions, and Ergometrine, to make the uterus clamp down tight afterwards.

The advantages of an actively managed third stage are that the third stage is usually over quickly, and average blood loss is lower. The mother does not usually have to 'do' anything - she just waits, while the drugs and the midwives do the work!

The disadvantages of an actively managed third stage for the mother are:-

Cord Clamping: issues for the baby

Active management has serious drawbacks for the baby IF the cord is clamped before it has ceased pulsating. It is not necessary for Syntometrine to be given this quickly, but usual practice in the UK is to give the injection as the baby's shoulders are born, or immediately after the birth. The cord is usually clamped before the injection is given, because of theoretical concerns about the powerful shunt of blood from the induced contractions causing an 'overtransfusion' - the baby getting too much blood, which could lead to polycythaemia (causing a serious form of jaundice). Current evidence appears to suggests that neither of these is a real risk. The downside of early cord clamping is that the baby does not get the benefit of the oxygen-rich blood in the cord and placenta which would come to it in a natural third stage. This is now known to increase the baby's risk of becoming anaemic in infancy. Moreoever, the oxygenated blood in the cord and placenta would normally tide the baby over for the few minutes while the cord pulsated, providing extra oxygen while the baby established breathing. This cord blood is rich in stem cells, and we do not yet know if these have a role to play in recovery from birth.

Delaying cord clamping for a few minutes after the baby is born is now becoming rather mainstream, thankfully; the Daily Mail has even published an article on it!

Another recent article by a US obstetrician, Nicholas Fogelson MD, discusses 'Why delayed cord clamping should be standard practice in obstetrics'. The comments section is extensive and well worth a read, containing input from midwives, doctors and birth supporters from varied backgrounds. Follow-up articles and video presentations are also available.

See also the Facebook page - Delayed Cord Clamping UK.

For more discussion of the effects of early clamping on the baby, see Cordclamp.com - retired obstetrician George Morley has specialised in compiling information about the best way of managing cord clamping, and of the risks associated with early clamping.

Much of the research on cord clamping is fairly recent and practices in obstetrics are only just starting to change. It is now being questioned whether early clamping is indeed necessary after an injection of syntometrine, but as early clamping is currently standard practice, you may find that your caregivers are either not up to date with the latest research, or disagree with it. This is changing rapidly in the care of premature babies, and is starting to filter through to the mainstream.

Here, for example, is a quote from a letter to the BMJ from a consultant obstetrician, explaining why his unit has changed arrangements so that they can resus after caesareans with the cord still attached:

From http://www.bmj.com/cgi/eletters/333/7575/954 "Fetal distress is a common reason for instrumental delivery or caesarean section. The fetal compromise is often due to cord compression associated with a nuchal cord. A nuchal cord results in compression of the low pressure venous return of oxygenated blood from the placenta. Blood continues to be pumped out by the fetal heart and the obstructed return from the placenta results in a congested placenta and a depleted fetal blood volume.

If the cord is clamped immediately at delivery, although the return from the placenta is now relieved, the excess blood, which is oxygenated blood, never has any opportunity to return to the newborn.

In these circumstances it is particularly important to be able to resuscitate the baby with the cord return still intact. Preparation for neonatal resuscitation needs to be made at the same as preparation for the caesarean section. Every maternity unit in the UK needs to adopt these guidelines.

David Hutchon

There are quite a few other interesting letters on that BMJ letters page, with a number of references to research on cord clamping and anaemia etc..

The Journal of American Medical Association published a meta-analysis of early versus late cord clamping in full-term newborns, which you can read in full here:

http://jama.ama-assn.org/cgi/reprint/297/11/1241

They found that there was no increase in the incidence of clinical jaundice or need for phototherapy with 'late' cord clamping, although there was some increase in neonoatal polycythaemia. In the higher-quality studies this association did not reach statistical significance.

What they DID find was that late clamping was associated with better iron status, as measured by serum ferritin levels, to six months and beyond, and also with less anaemia in the newborn periods. The babies who were breastfed and who experienced 'late' cord clamping had proportionately higher iron stores at six months than the babies who were no longer breastfed.

Abstract copied below.
See also NHS electronic library for health discussion of the paper
http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?View=Full&ID=12007008099

This subject is returned to in the section below on resuscitation with the cord intact.

Physiological or 'natural' third stage

'Physiological management', or a 'natural' third stage, means that drugs are not automatically administered to deliver the placenta, but that the woman waits for it to arrive naturally, and drugs can be given at any time if blood loss seems worrying or if she decides she has waited long enough. If, at any stage, the woman's blood loss worries her or her midwives, she still has the option of having drugs to push out the placenta and control bleeding.

The downside of a 'natural' third stage is that it takes longer to deliver the placenta, on average, and that average blood loss is higher. The Hinchingbrooke trial of active management versus physiological third stage found that 16.5% of women had a clinically significant blood loss of 500mls or over with physiological management, against 6.8% with active management. But when you look at the overall difference in blood loss, as opposed to the number of women who passed that threshold, it was only an average of 80mls approximately (if I recall correctly - will confirm that soon) [Rogers et al, 1998]

How long does a physiological third stage take?

Perhaps not as long as you might think. Research suggests a physiological third stage takes only 9.7 minutes longer than active management, on average [4, Cochrane review]. Yet it is quite common for a natural third stage to take half an hour or an hour or more, although ten minutes is also perfectly normal. Why should it have a reputation for taking so long? In a discussion on third stage [LINK currently DOWN while that site is restructured], a UK midwife commented:

In most normal cases, a placenta will detach from the wall of the uterus within ten minutes (whether you give an oxytocic or not.) Ultrasound studies show this. Sitting around for a couple of hours waiting for the thing to fall out after it has separated is dull, and can be dangerous.

What almost always happens, if you watch carefully and disregard the things you think you know about third stage, is this. The baby is born and the cord pulsates forcefully. The mother greets the baby and gives him or her her full attention. Within three to five minutes she will have a contraction and will usually look up and go 'ooh.' Within five to ten minutes she will have another, nasty contraction and go 'ow,' and whatever she is doing she'll normally shift around uncomfortably. This is because the placenta has hit her cervix. If you feel the cord, then, it may be pulsating, but the pulsation will be weak and thready. If she is in, or gets in an upright position, the placenta will normally plop out. Well within fifteen to twenty minutes.

So what is different about a natural third stage? The mother has to be actively involved in the birth of her placenta; she must push it out herself, and sometimes this involves moving around, and trying different positions and techniques, although, as the experiences below show, it often takes no more than standing up as the placenta slips out. Your baby can be close to you while you are doing this, of course, and for many women a physiological third stage means no more than sitting down,and cuddling the baby for ten minutes or so until she feels the urge to push the placenta out.

While you are waiting, your midwives should observe carefully and may offer advice on techniques to help push the placenta out. For instance, some women find that if they push as if they were trying to do a poo (bowel movement), the placenta rapidly appears. Some midwives recommend that women blow into a bottle to help push the placenta out. A full bladder can make it difficult to pass the placenta; if you find it difficult to urinate, you could try a warm shower or bath, or your midwives may catheterise you.

If you do not have drugs to aid delivery of the placenta, you can choose to either have the cord cut when it has stopped pulsating, or to wait until the placenta is delivered. This last choice is a great excuse to keep your baby 'velcroed' to you straight after birth, rather than having him whisked off to be weighed and measured while you get on with delivering the placenta. On the other hand, some women feel they can't concentrate on delivering the placenta while still attached to their baby. There is some speculation that leaving the cord uncut until the placenta is delivered might somehow help speed up the delivery of the placenta, but I am not aware of any strong evidence for or against this.

I have had physiological third stages for all of my five babies, but while the cord was cut when it stopped pulsating after the first, I left it intact until the placenta was delivered for the others. Personally I really valued the peaceful bonding time this latter choice gave me and my babies. The first time it took about an hour and a quarter and was unpleasant - the cord was cut when it stopped pulsing, and I spent ages sitting there, cold, trying to push the placenta out, while clots built up behind it. The midwives were very relaxed about natural third stages and believed that it was normal for them to take an hour on average. The placenta was separated but I could not feel any contractions to push it out, and eventually passed a large amount of blood clots which had built up inside me behind the placenta, before the placenta came out. After that I swore that I would choose a managed third stage next time, because I felt that precious first hour with my baby had, instead, been spent trying to have a placenta. However, after reading about different approaches to a physiological third stage I decided to be more proactive next time, and it worked beautifully; none of my subsequent third stages took more than 20 minutes, several less than 10, and during that time I was snuggled up with baby having a nice cup of tea! Blood loss was minimal. I had decided that, if the placenta did not arrive within 15 minutes or so, I would ask the midwife for help delivering it and, if that did not get results quickly, have the injection. What worked for me was pushing as if I was having a bowel movement, as soon as I started to feel anything at all!

Michel Odent apparently teaches that it is important to keep oxytocin production up in the third stage, in order to help push the placenta out and contract the uterus down. Things which help this:

Personally I worry about staying in a birth pool for the third stage because I believe that we hear about more long and difficult third stages when this happens. It may be that the birth pool relaxes some women too much and it is difficult to get strong enough contractions for the third stage. It can be hard for the midwife to keep an eye on blood loss, particularly if the room is dark. A third stage in water can be hassle for other reasons; it can certainly be difficult to keep both mum and baby at a comfortable temperature and to give the baby its first feed, while ensuring that both water level and water temperature are perfect. There is some discussion about this on the page about waterbirth, but I plan to expand on it soon. I am not aware of any research evidence on the safety of conducting the third stage in water, and while certainly many women do it with no problems, it seems reasonable to question it; it's certainly not something we have evolved to do.

Resuscitation with an intact cord

Please see the section above on 'Cord clamping - issues for the baby'.

If the baby needs some form of resuscitation, this can be administered while the baby is still attached to the cord - giving it the benefit of all the oxygenated blood in the placenta, as some still pulses down the cord for a few minutes after birth - if the midwife has her equipment near the mother, or if the mother can move to the resus area. If the mother cannot move to the resus area then the midwife can quickly clamp and cut the cord, just as she would in a managed third stage. However, the disadvantage of this is that the baby is deprived of the oxygenated blood which is already in the cord and placenta, and which would be transfused to the baby over the next few minutes - buying it vital time to establish breathing. Increasingly, experienced midwives and obstetricians are resuscitating with the cord attached wherever possible.

The British Medical Journal's editorial on 18 August 2007 focussed on this issue, and concluded:

"Early clamping and cutting of the umbilical cord is widely practised as part of the management of labour, but recent studies suggest that it may be harmful to the baby. So should we now delay the clamping? ..."

"How should we approach cord clamping in practice? In normal deliveries, delaying cord clamping for three minutes with the baby on the mother's abdomen should not be too difficult. The situation is a little more complex for babies born by caesarean section or for those who need support soon after birth. Nevertheless, it is these babies who may benefit most from a delay in cord clamping. For them, a policy of "wait a minute" would be pragmatic.11 Indeed, this first minute is already largely spent on neonatal assessment. This could be done in warmed towels on the birthing bed or the mother's abdomen after vaginal delivery, or on the mother's legs at caesarean section. Cord clamping need only take place when transfer to the resuscitation trolley is required.... "

"There is now considerable evidence that early cord clamping does not benefit mothers or babies and may even be harmful. Both the World Health Organization and the International Federation of Gynecology and Obstetrics (FIGO) have dropped the practice from their guidelines. It is time for others to follow their lead and find practical ways of incorporating delayed cord clamping into delivery routines. In these days of advanced technology, it is surely not beyond us to find a way of keeping the cord intact during the first minute of neonatal resuscitation. "

You can read the full text of the BMJ Editorial on Cord Clamping online: BMJ Cord Clamping editorial - pdf
BMJ Cord Clamping editorial - .rtf
Please see Links section below for more links to the original editorial, and to responses from midwives and obstetricians.

More information on resuscitation at homebirths, and birth stories where resus has been given in different ways, can be found on What if your baby needs resuscitation at home?

An excellent article explaining many of the arguments against routine intervention in the third stage is: Third Stage of Labour Benefits of A Natural Approach, By Dr Sarah J Buckley
http://www.bellybelly.com.au/articles/birth/natural-approach-to-labour

Birth Plan for Third Stage:

Here is an extract from the page on Birth Plans, about choices for third stage:

There are four main variations to choose from, but of course if the midwife is worried about your blood loss then (with your permission or without, in an emergency) drugs may be needed, whatever your plans.

I plan to have an actively managed third stage and understand that the midwife will administer syntometrine/syntocinon/whatever drug is used in her practice, when she feels it appropriate, and that the cord will be clamped and cut soon after the baby's birth.

Or:I would like an actively managed third stage, but with cord clamping and cutting delayed until the cord has stopped pulsating. After this, I would appreciate it if you could administer drugs to help me deliver the placenta.

Or:I would like a physiological third stage with the cord clamped and cut when it stops pulsating. I wish no drugs to be used unless specifically indicated. It is important to me that you do not clamp the cord until it has stopped pulsating, unless you need to take emergency steps which preclude this. **Please do not pull on the cord or use fundal pressure unless there is a specific indication to do so, as I have read that this is contra-indicated in drug-free third stages**.

Or: I plan to have a fully natural (physiological) third stage, and to cut the cord only after the placenta is delivered. I want to allow the placenta to turn up in its own time. It is important that the cord is not clamped or cut until the placenta is delivered. Please do not administer any drugs unless you feel there is a real need. I would appreciate your advice to help me deliver the placenta naturally. **Please do not pull on the cord or use fundal pressure unless there is a specific indication to do so, as I have read that this is contra-indicated in drug-free third stages**.

Birth Stories

Here are some birth stories from women who chose various approaches to the third stage of labour at home births:

Helen H started off with a physiological third stage but opted for the injection after 20 minutes or so - her placenta came quickly. Her second baby was born before the midwife arrived after a rapid labour, and "We were just about to discuss 3rd stage labour when nature answered the question for us. Plop! Out came the placenta and sploshed onto the floor."

Gina R had a 5-hour third stage after a long, tough labour with her first baby. After trying various positions and homeopathy, she delivered the placenta with syntometrine. She went on to have a Lotus third stage, with the placenta separating after two and a half days.

Lynne D had a long third stage in a birth pool and moderate blood loss.

Emma Barrett had 'expectant management'; she hoped for a physiological third stage, but the midwife was worried about her bleeding shortly after the baby's birth, and so switched to a managed third stage.

Amanda B: While Dennis was in my arms, the I received the injection and the midwife tugged on the cord. I felt really scared at this point as it was the only part of the labour that I didn't feel I was in control. However, the placenta just slid out easily and I didn't feel a thing.

Brenda: "I decided to get out of the pool for the third stage, and wobbled to the sofa to gaze in besotted admiration at my baby, and await the placenta while Henry latched on. Then - oh, bum! More contractions. "Why am I having a physiological third stage again?" I wondered. However, I knew perfectly well why I was having one - and about one contraction later, I realised it might help if I moved my big bottom off the sofa, as sitting down was probably not the most conducive position. Sure enough, the moment I moved, out it came - masterfully caught by a midwife with a kidney dish and reflexes a rattlesnake would be proud of."

Rosie Evans wanted to wait and see how the third stage went, before deciding on a management plan. Her daughter's cord was clamped and cut after a minute or so because the midwives wanted to give her some resus out of the pool, and after that: "After a few minutes holding her in the water I decided to have the injection for third stage because I wanted to get out of the pool and into bed ... Six or seven minutes after the injection nothing had happened so with a little help I stood up, and just as I did the placenta fell out.."

Rebecca had wanted the cord left to pulsate, but the midwife didn't realise this and clamped it immediately. Her daughter was a little slow to get going, but was OK in the end. Rebecca writes: "I waited 10 minutes or so for the placenta then took the syntocinon injection to bring it on. Out it came, whole and fine. I lay with my baby and sang a song to her we'd shared when I was pregnant."

Emma: We waited for the cord to stop pulsing, and whilst waiting mummy cuddled and tried to feed.  Daddy then cut the cord, after which Daddy had a chance to have a cuddle, after the vitamin K injection had been administered. I was told I would have to get out of the pool for the third stage. And although I had decided not to have the injection, I did change my mind, I was so tired and just wanted it over with. This again was relatively painless and then I was given my baby back and I was a mummy.

Joy bled heavily as her baby was born, but she wanted her baby to benefit from a physiological third stage. She stopped the midwife from clamping the cord, waited for cord to stop pulsing then had syntometrine, which was very effective.

Donna Cummings had a managed third stage in an unhurried way - her baby was born, they said hello, the midwives rubbed him down and then she had the injection.

Amber: "I wanted a physiological third stage, so after about half an hour the midwife asked if I could stand up to see if the placenta would arrive with the help of gravity, but it was a bit more stubborn than that and didn't arrive for another half an hour with a bit more pushing from me. I wasn't concerned but the midwife was getting a bit edgy, and at one point after examining me said she could see the placenta just sat waiting for me to give a shove, and she tugged a bit on the cord. This was naughty as with a natural third stage she should have been hands-off had the cord come away this could have caused complications, but as it was everything was fine and I had estimated blood loss of 300ml."

Kate Marshall waited for the cord to stop pulsing, then had the jab: "I had initially planned to try for a physiological third stage with the cord to be cut once it has stopped pulsating but had indicated that I would be willing to have the injection if required. Given the epic duration of the stop start labour and my general exhaustion the midwife had already asked me earlier if I would consider the injection once the cord had stopped pulsating and I had agreed that things had really gone on long enough. Once the cord stopped pulsating my husband cut it. ..The midwives administered the injection to deliver the placenta and asked me to lay down (as it later transpired they were concerned about the bleeding). The third stage took a total of 5 mins."

Rachel White had a homebirth after two caesareans: "We waited for the cord to stop pulsing before Curtis cut it. We tried for a physiological third stage but blood was gushing so had the injection and delivered the placenta."

Victoria Whitworth chose a physiological third stage; her midwives said they would like her to have syntometrine after an hour, but the placenta turned up after 59 minutes.

Kirsty Crowther had a natural third stage but her placenta was a bit slow, so on her midwife's advice, she delivered it by pulling on the cord herself.

Fiona's placenta took over an hour to arrive naturally with both of her babies. Her midwife encouraged to stand up and try a soothing shower, which did the trick.

Debbie Dooley chose a physiological third stage partly because she is diabetic and her research suggested this would help to stabilise her baby's blood sugar levels. The delivery of the placenta took some time but was not a problem: "We left his cord to stop pulsing and he had his first feed whilst he was still attached to me. Daddy cut his cord around 15 minutes later and had his first cuddle whilst I started pushing again to deliver the placenta. It took about an hour for the placenta to come out naturally, and Caiden fed wonderfully and helped it to detach."

Jem had an unusually painful third stage after the birth of her fourth baby. She did not have syntometrine, and "the midwives said later that it was just as well I hadn't had it, if anything had caused my uterus to contract down any harder I would have been in far more pain, which really doesn't bear thinking about."

Melanie Renowden chose a managed third stage: "I lay down on the bed and had a lovely cuddle while the midwife gave me the injection for the placenta. It was delivered very quickly and easily."

Sally Paech picked up her baby to give her her first cuddle. "I think time stood still while we all marvelled at what had just happened. What seemed like ages after I felt something "drop" from inside me. I again went up on my knees only to have the placenta drop out. Apparently it was only minutes."

Kirsty Nicol gave her body a chance to deliver the placenta on its own, but after waiting a while she moved to a managed third stage: "the placenta just didn't seem to want to budge, and after kneeling up at one point, I suddenly felt hot and dizzy. Quickly the midwives had me lying down, and I was feeling willing to go for the assisted 3rd stage after all." - after which her placenta arrived quickly and easily.

Jeanette was keeping an open mind about her third stage, and after the birth she started to bleed heavily so her midwife suggested an injection of syntometrine, which she had and which worked well. When she had her next baby, Sidney, she was again keeping an open mind, but felt so rotten after the birth that she couldn't stand the thought of waiting for a physiological third stage, and so chose syntometrine again.

Rebecca planned a physiological third stage but, after over an hour "In the end I decided that I had had enough, wanted to get into bed and lie down so I asked for a shot of syntometrine. After this the placenta came out very easily"

Gillian chose physiological management for her third stage, but her midwives were not experienced in hands-off approach, and started hassling her to deliver it in strict time limits. When an hour was up, she used homeopathic remedies, apparently to great effect.

Lonnie Fletcher chose active management after the birth of her second baby, Eloisa, and physiological third stage after the birth of her fourth baby, Aoife.

Sarah Sadler had a home birth and wanted a physiological third stage, but after waiting for the placenta for an hour, decided to use Syntometrine instead.

Brigett English said "I had planned to deliver the placenta naturally, but all I wanted to do was to be with my baby. So the placenta is delivered with the help of an injection.."

Christine chose to have Syntometrine for the third stage of her twins' waterbirth, but it made her sick.

Catriona considered a natural third stage for her third and fourth babies, after unmedicated labours, but each time chose to have syntometrine to get the delivery of the placenta over quickly.

Karen had a natural third stage with her second baby, Lewie, after having had a retained placenta with her first baby.

Kedi had planned to delay cutting the cord until the placenta was delivered, after Beth's home waterbirth, but in the event she wanted to get it over with, so chose to have the cord cut when it stopped pulsating. When her third baby, Isaac, was born, she again wanted to delay cord cutting, but this time the delivery of the placenta took two hours and was quite difficult.

Helen was just getting bored waiting for her placenta to turn up, when it decided to co-operate.

Vivienne writes that " I'd asked for a physiological third stage and amazingly, it was all over and done with just five minutes after Gabriel was born"

Emily had a fully physiological third stage, minimal blood loss, and cut the cord after the placenta was delivered.

Sarah Calvert waited half an hour for the cord to stop pulsating before cutting it, and then her placenta arrived naturally one hour later.

Emma planned a homebirth for her twins, but transferred to hospital for slow progress. Her waters were broken in hospital, then she gave birth to her twins under her own efforts and had a physiological third stage with very little blood loss.

Tric was dreading the third stage after finding the delivery of the placenta difficult in her three previous hospital births, but with the encouragement of her confident midwife, she delivered it very easily after her waterbirth. She did not have syntometrine for the delivery of the placenta, but because of heavy bleeding she was given the drug afterwards - a "wait and see" third stage.

Carrie planned a physiological third stage but consented to syntometrine when there was a gush of blood after her baby's birth - another good example of "expectant management".

Aida chose a 'lotus' third stage for her baby - the cord was left uncut, with placenta attached, until it separated naturally from the baby. Baby Maia was born in poor condition and needed resusctiation, but this was done with her still attached to her mum.

Sara Gonzales had hospital births with managed third stages for her first two children, and chose an injection of syntometrine for her homebirth as well, as she did not want to wait for the placenta or have to push it out. She had no problems and did not experience any pain when her midwife used cord traction to help her deliver the placenta.

Helen O'Donnell had a physiological 3rd stage with no problems: " I just squatted and I think it just fell out!"

Alicia waited until her first baby's cord stopped pulsating before clamping and cutting. "About ten minutes later I stood up and delivered the placenta, no problem at all. "

Sarah H writes: "My contractions completely stopped once the baby had arrived. I had chosen to have natural third stage and wanted to have time to cuddle my baby, but the midwife was very keen that I get on and finish the job. As there did seem to be a lot more blood in the pool after this birth than the last, I did eventually agree to stand and try pushing the placenta out which worked fine.

Fiona B's second baby arrived very quickly, but her placenta was not in such a hurry: "This took just over an hour, which was starting to worry us, but the threat of a transfer to hospital gave me the incentive to push harder, and it was all fine."

Willow says that immediately after her daughter's birth, "I asked for the injection to speed up the delivery of placenta. I had romantically hoped to breastfeed instantly and slip it out like a real mammal, but in reality I just wanted birth over with.". She had no problems with her managed third stage and it took 13 minutes.

Jessica B: "I intended to get out of the water to have a physiological 3rd stage but I was enjoying cuddling this wailing child and didn't want to leave the pool. ...I was just planning on getting out when I had 3 strong but painless convulsions in quick succession & the placenta fell out to the bottom of the pool.  James' cord was subsequently clamped and cut and we got on to dry land again."

Rosie had a 'wait and see' third stage: "I had wanted a natural third stage, but the placenta didn't want to shift. The MW's encouaged me to go to the loo..I sat there for ages, but it really wasn't happening, so I then shuffled back to my bed and had the injection. The placenta followed a couple of minutes later."

Miriam had a home waterbirth with her first baby, and ten minutes later stepped out of the birth pool and delivered her placenta with "no fuss whatsoever"; she had a natural third stage and the midwife simply pulled gently on the cord. Her estimated blood loss was 250mls, which is about average.

Angela Horn

Links

Postpartum Haemorrhage - how would PPH be treated at a home birth? (on this site)

The Third Stage of Labour, from the UK Midwifery Archives - active versus physiological management, and other topics (www.radmid.demon.co.uk/pph.htm)

Review of the Literature on Umbilical Cord Clamping - by Judith Mercer
Journal of Midwifery and Women's Health, November 2001

Why early cord clamping at birth must stop now! By Dr David Hutchon (a UK obstetrician)

Cordclamp.com - retired obstetrician George Morley has specialised in compiling information about the best way of managing cord clamping, and of the risks associated with early clamping. His site is now archived on Dr Hutchon's site - this is the direct link to it.

Third Stage of Labour Benefits of A Natural Approach, By Dr Sarah J Buckley
Fab article drawing together the evidence and arguments in favour of a physiological third stage.
http://www.bellybelly.com.au/articles/birth/natural-approach-to-labour

You can read the full text of the BMJ Editorial on Cord Clamping online:
BMJ 2007;335:312-313 (18 August), doi:10.1136/bmj.39282.440787.80
Late vs Early Clamping of the Umbilical Cord in Full-term Neonates
Systematic Review and Meta-analysis of Controlled Trials
Eileen K. Hutton, PhD; Eman S. Hassan, MBBCh
Editorial on the BMJ Website - subscribers only until August 2008 (http://www.bmj.com/cgi/content/extract/335/7615/312)
Responses to BMJ - includes interesting comments from midwives and obstetricians - free to all on the BMJ website. Copy of BMJ Cord Clamping editorial - pdf
Copy of BMJ Cord Clamping editorial - .rtf

Delayed clamping of the umbilical cord does no harm and reduces anaemia in newborns
BMJ 2006;332 (13 May), doi:10.1136/bmj.332.7550.0-e

References

Journal of the American Medical Association

JAMA. 2007;297:1241-1252.

Context
With few exceptions, the umbilical cord of every newborn is clamped and cut at birth, yet the optimal timing for this intervention remains controversial.

Objective
To compare the potential benefits and harms of late vs early cord clamping in term infants.

Data Sources
Search of 6 electronic databases (on November 15, 2006, starting from the beginning of each): the Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Neonatal Group trials register, the Cochrane library, MEDLINE, EMBASE, and CINHAL; hand search of secondary references in relevant studies; and contact of investigators about relevant published research.

Study Selection
Controlled trials comparing late vs early cord clamping following birth in infants born at 37 or more weeks' gestation.

Data Extraction
Two reviewers independently assessed eligibility and quality of trials and extracted data for outcomes of interest: infant hematologic status; iron status; and risk of adverse events such as jaundice, polycythemia, and respiratory distress.

Data Synthesis: The meta-analysis included 15 controlled trials (1912 newborns). Late cord clamping was delayed for at least 2 minutes (n = 1001 newborns), while early clamping in most trials (n = 911 newborns) was performed immediately after birth. Benefits over ages 2 to 6 months associated with late cord clamping include improved hematologic status measured as hematocrit (weighted mean difference [WMD], 3.70%; 95% confidence interval [CI], 2.00%-5.40%); iron status as measured by ferritin concentration (WMD, 17.89; 95% CI, 16.58-19.21) and stored iron (WMD, 19.90; 95% CI, 7.67-32.13); and a clinically important reduction in the risk of anemia (relative risk (RR), 0.53; 95% CI, 0.40-0.70). Neonates with late clamping were at increased risk of experiencing asymptomatic polycythemia (7 studies [403 neonates]: RR, 3.82; 95% CI, 1.11-13.21; 2 high-quality studies only [281 infants]: RR, 3.91; 95% CI, 1.00-15.36).

Conclusions
Delaying clamping of the umbilical cord in full-term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy. Although there was an increase in polycythemia among infants in whom cord clamping was delayed, this condition appeared to be benign.

Author Affiliations: Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario (Dr Hutton); and The Child and Family Research Institute (Dr Hutton), Western Regional Training Centre for Health Services Research (Dr Hassan), and Department of Health Care and Epidemiology (Dr Hassan), University of British Columbia, Vancouver.

[4] The Cochrane review of active management for third stage says physiological third stage takes an average of 9.7 minutes longer than active management. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000007/frame.html

This page updated 22 January 2010.

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