The third stage of labor is often an aside or an afterthought; however, this stage of labor is significant for many reasons. Its important to understand the physiology of this phase, as well as to understand common interventions when things aren’t going exactly as anticipated

After the birth of baby, whether vaginally or by cesarean, a person is still considered pregnant until the placenta is birthed. In the first couple of minutes after the birth of baby, the umbilical cord continues to pulsate, delivering oxygen-rich blood to baby as they transition to breathing air for the first time! As long as all is well with you and baby, both the American College of Nurse Midwives and the American College of Obstetricians and Gynecologists recommends waiting at least 30-60 seconds to clamp and cut the cord.

Although the cord is most often clamped and cut in the first few minutes after birth, in a vaginal delivery, it is normal for it to take at least 5-30 minutes for the placenta to be born (during cesarean delivery, the placenta is typically removed manually). During this time, especially in a hospital setting, your nurse or provider may proactively encourage the placenta to come in order to encourage your uterus to involute, or shrink down, to stop postpartum bleeding.

Active Management of the third stage of labor:

  1. Fundal “massage” (usually every 15 minutes for the first two hours after baby is born). The term massage here is pretty misleading, as there is nothing that feels good about kneading your uterus after you’ve just pushed out a baby. It is an uncomfortable experience and one that often requires us to use many of our labor coping tools- breathing, distraction, vocalization. As uncomfortable as this procedure is, some studies have shown this technique to significantly reduce blood loss and the reduce need for other medications to manage postpartum bleeding when used alone. However, that study and others also showed that fundal massage may not significantly reduce postpartum blood loss when other uterotonics (medications used to induce uterine contractions) are already in use.
  2. Uterotonics. Pitocin is the most commonly used uterotonic medicine and is considered the most effective agent for preventing postpartum hemorrhage. This synthetic form of oxytocin binds to the uterine receptors, causing the uterus to begin shrinking down, and helps control postpartum bleeding. While small amounts of Pitocin are often used in labor induction and augmentation, much larger amounts are used to control postpartum bleeding. Fortunately, after the baby is out, these higher doses of Pitocin tend to cause little more than some physical crampiness. In cases where Pitocin alone is not adequately tapering bleeding postpartum, other medications and techniques may be used, including misoprostol (Cytotec®), Methergine®, and Hemabate®, as well as the use of sterile gauze or balloon tamponades (a balloon filled with saline inside the uterus to compress the bleeding vessels).  
  3. Controlled cord traction. Gentle or controlled traction on the cord means that a provider uses a gentle pulling on the cord to encourage the placenta to be born. There is limited evidence for the use of controlled cord traction in the management of postpartum bleeding and the use of cord traction is associated with some risks such as uterine inversion or prolapse. The use of cord traction is a manual skill that requires considerable practical training.

Expectant Management of third stage labor

In contrast to active management of the third stage of labor, some providers and individuals giving birth prefer “expectant management” of the third stage, as it is viewed by many as being more physiological and less interventionist. Included in this approach is more of a “wait and see” mentality regarding managing postpartum bleeding. In this approach, providers wait for the signs of placental separation and spontaneous delivery of the placenta, unless there is enough bleeding to warrant using Pitocin.

Often in expectant management, skin-to-skin contact, breastfeeding/bodyfeeding or other nipple stimulation is encouraged to help the body’s own oxytocin levels surge. While these techniques have been used throughout human history, there is evidence that active management of the third stage significantly reduces the chances of postpartum hemorrhage, especially in situations where the risk for postpartum hemorrhage is greater (birthing multiples, prolonged labor, labor induction, among others).

We encourage you to speak with your care providers about what to expect in the first hour after baby’s birth, what options you have around management of the third stage of labor, and how they may best support you during that sensitive, transformative time immediately following your baby’s birth!

About the author

Lindsay Wolff, PhD, CD (ToLabor), BCCE (BACE)

I have always been interested in the “whys” and the “hows” of different systems. The same inquisitive pieces of myself that led me to disassemble and reassemble radios and clocks as a child led me into the hard sciences (I was an atmospheric chemist in my previous career); then, into doula work and childbirth education. I have a passion for evidence-based information, for understanding the physiology and structure of systems and for helping others get excited about learning too. After the amazing home birth experiences of my daughters, I began daydreaming about birth work. I had the incredible privilege of being able to quit my job in academia to pursue midwifery studies and to attend births as a doula. While it was the “sunshine and rainbows” (the joy of seeing parents meet their little ones for the first time, the pride and accomplishment that people feel after birthing their babies and taking ownership of their experiences and decisions) that got me into birth work, it is the harder stuff that has made me stay. I provide trauma-informed, sensitive, and loving doula care through the most joyful and the most difficult moments.