What Is a Truly Physiological Third Stage/Retained Placenta
Can it really happen under current birthing practice and how can it happen?
The longest placental delivery I had ever seen until recently was at a freebirth – 3.5 hours, it was a beautiful time, the parents and I just sat – chatting, it was beautiful, mum held baby and we sat by the firelight gently, quietly together, bonded in spirituality – and then – the placenta just arrived, no fuss, no panic, just there it was. This is exactly how the birth had unfolded. Peaceful, unhurried, in the dark.
Dad tied off the cord and separated the baby from the placenta that had grown her for the last 9 months. Which somewhat amusingly was being stored in a Celebrations tin.HERE on my blog.
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This is a total opposite to an NHS “physiological third stage”, this is not a dig at midwives, who are often out there doing their job to the absolute best of their ability within their professional guidelines – which are – if the placenta is not delivered within an hour, to
“diagnose a prolonged third stage of labour if it is not completed within 30 minutes of the birth with active management or within 60 minutes of the birth with physiological management”
(NICE Pathways – “Care In The Third Stage Of Labour”).
The birth of the baby – however hands off the birth has been, is often accompanied by a massive sense of excitement, which is not conducive to maintaining a low light, calm environment for birthing the placenta.
This is often followed by an increasing sense of panic if the placenta does not arrive in 20 minutes, never mind an hour, regardless of the womans clearly documented wishes for a physiological third stage.
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I quite seriously believe the NHS, its training and therefore its staff, have lost sight of what a completely hands off birth (including placenta) actually looks like. A midwife I was talking to made an interesting point that I have probably seen more physiological third stages than them (and probably more homebirths than a lot of her midwife colleagues as well).
Personally I think experience of all types of birth should be mandatory in training so that nothing is unfamiliar. If you have never seen a homebirth, a hands off birth, a physiological third stage, how can you be comfortable supporting it.
In order to achieve a truly physiological third stage then it needs to be totally hands off, no touching, no cutting, no encouraging the woman to move, no clock watching, no panicking, allowing that woman to accept responsibility for her body, in the same way she did birthing her baby and definitely no weighting the cord with the clamps as I have witnessed more than once.
I rarely if ever see this and the majority of my clients chose a physiological third stage – instead I see and sense the growing panic as time passes, the fear in the room, with the best will in the world, becomes so thick it becomes almost palpable, I witness the moving of women, the encouragement to push, purple pushing, try squatting, try moving, try standing, try shifting, pass baby to dad, we must get that placenta out.
All of these things will impact on the physiological third stage and make a haemorrhage, a retained placenta, partial or full, much more likely, especially separating woman and baby.
I have seen midwives pull on a cord in a physiological third stage, causing a woman to scream in pain and I have seen pulling on a cord happen in a twin birth, where despite not being supposed to have a medical opinion I was about to point out the inadvisability of this – when a second midwife advised the first to stop pulling as it was a physiological third stage “but it is twins” came the reply – so that lessens the risk of haemorrhage or the cord snapping by pulling on it does it?
The Royal College of Midwives in their document, “The Third Stage of Labour” (no longer available online), stated
Applying active management principles in physiological management (palpating the uterus, and/or applying cord traction) may lead to increased bleeding (Begley 2011). Variations in PPH rates have been identified (Lu et al. 2005) and linked to level of practitioner expertise in third stage care (Goudar et al. 2008) and management style (Logue 1990). The last author concluded that when managing the third stage, more conservative and patient practictioners have lower PPH rates than the ‘impatient and heavy-handed’.
Their recent blue top guidance states
There is some evidence that active management of the third stage of labour reduces the risk of severe bleeding and anaemia for all women1. However active management may increase the risks of adverse effects such as increasing mother’s blood pressure, vomiting, after-pains and the need to return to hospital with bleeding.
Which based on observation I totally concur with. I have yet to see a physiological third stage in which the uterus is not being palpated other than at a freebirth.
If it is documented in a womans notes that all risks have been discussed and the woman and/or her partner sign to say they accept those risks – then there can be no suing the midwife. No blame cast – the woman is responsible and always has been.
This message is beginning to seep into birth – when I ask myself will it seep into the third stage as well.
If a woman is bleeding step in – but otherwise consider finding faith and trust and perhaps leave it be. Quoting the same Royal College of Midwives report – ” If the placenta is retained after one hour, active management should be considered (NICE 2007; Prendeville et al.1988).” Note is says “SHOULD”, not “MUST”.
Aims – “Birthing Your Placenta” is an excellent read and discusses a lot of this in more detail.
NICE Guidelines “Recommendations For The Third Stage” show increased risks in a physiological third stage, but these risks are still very low and only in small in number and as with all NICE Guidelines it is made clear that the womans informed choice should be respected.
Based on observation I have to wonder if some of the increased risk comes from an inability to allow a truly physiological third stage, the RCM publication seems to think so.
1.14.7 Explain to the woman that active management:
- shortens the third stage compared with physiological management
- is associated with nausea and vomiting in about 100 in 1,000 women
- is associated with an approximate risk of 13 in 1,000 of a haemorrhage of more than 1 litre
- is associated with an approximate risk of 14 in 1,000 of a blood transfusion. 
1.14.8 Explain to the woman that physiological management:
- is associated with nausea and vomiting in about 50 in 1,000 women
- is associated with an approximate risk of 29 in 1,000 of a haemorrhage of more than 1 litre
- is associated with an approximate risk of 40 in 1,000 of a blood transfusion. 
1.14.11 If a woman at low risk of post partum haemorrhage requests physiological management of the third stage, support her choice. 
This article discusses the risks of a retained placenta including post partum haemorrhage and fatality, “Retained Placenta” and interestingly states
“The incidence and importance of retained placenta vary greatly around the world:
In less developed countries, it affects about 0.1% of deliveries but has up to 10% case fatality rate.
In more developed countries, it is more common (about 3% of vaginal deliveries) but very rarely associated with mortality. Retained placenta was identified as the cause of 18% of severe obstetric haemorrhages in one American series.”
What I have struggled to find in my research on writing this blog is the information on “how” in a physiological third stage the decision that anything more than an hour is “retained” with the “enormous” associated risks that are constantly associated with it.
I will amend this post if I find robust (or any) evidence for it.
According to “Birthing Your Placenta”
“There can be considerable variation in the length of time between the birth of the baby and the birth of the placenta where this occurs naturally. While up to one and a half hours is considered normal (Cronk and Flint 1989), many of the midwives who regularly attend physiological placental births report waiting much longer with no adverse effects.
One midwife researcher said she knows of no reason to interfere after an hour if time is not a constraint and that the decision to intervene after an hour is often a purely pragmatic decision in busy maternity units (Jane Rogers 1999 personal communication).”
Although it is not usual for partners or your baby to be in theatre if you are being treated for a retained placenta, as I doula I have taken a baby into theatre and sat next to a woman stroking her hair and singing to her. She refused to be treated unless her baby and I were both there.
For more information read my “All About Placentas” blog.
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Samantha Gadsden walks with women on their life’s journeys. She is an experienced Doula, based close to Cardiff in South Wales, mother to 4 children and wife to Eddie, more information can be found on her facebook page, Samantha Gadsden Doula and her website, Caerphilly Doula. SOS Doula, Telephone and online support is always available.
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