Birthing Your Placenta (or The Third Stage of Labour)

Natasha recently wrote an article for The Practising Midwife about physiological birth of the placenta. The Practising Midwife is a really informative journal, which challenges and expands our knowledge and understanding of physiology in labour and birth. Here, she writes about the different ways of birthing the placenta and the key role that continuity of care can play in supporting a physiological placental birth.

What Is a Physiological Placental Birth?

One topic that is neglected in mainstream midwifery education and practice is the physiological birth of the placenta. This is where the placenta is birthed spontaneously, without any medical intervention after you have birthed your baby. Birth is not complete until the placenta is born and it does require some physical effort. Your midwives and birth partner(s) need to maintain that oxytocin-rich environment in order to assist you in the physiological birth of the placenta.

What Is Active Management of the Third Stage?

The most common way women and birthing people birth their placenta in high-income countries is via something known as ‘active management of the third stage’. The term ‘third stage’ being the medicalised terminology for the part of your labour where the placenta is expelled from your body. The ‘active’ element refers to the administration of an oxytocic drug (syntocinon or syntometrine) via an intramuscular injection, usually in your thigh, very shortly after your baby is born. After the cord is clamped and cut, the placenta is then removed by your healthcare provider by gently applying traction to the umbilical cord. Active management is also used prophylatically to prevent a postpartum haemorrhage.

When Is Active Management Recommended Over a Physiological Third Stage?

In a physiological labour and birth, your body is pretty good at doing this but where there has been medical intervention and use of synthetic hormones such as syntocinon/pitocin during labour, an active third stage is clinically recommended to help reduce the risk of a haemorrhage. This is because if you have had medical interventions throughout your labour, there is a higher chance of having a postpartum haemorrhage – so an actively managed placenta may be the safer option for you. The practice of active management has become routine in hospital settings regardless of what type of birth you have and is recommended by NICE. What was once being used to manage a haemorrhage is routinely recommended to prevent a potential one even if you have an undisturbed physiological birth. It is important to note that whether you use the drugs or not, it is still possible (though not common) to have excessive bleeding.

Why Informed Choice About Placental Birth Is So Often Overlooked

For the majority of women and birthing people the birth of the placenta is often an afterthought. Some women have set feelings or cultural beliefs about the placenta but unless expressed, this part of childbirth is often neglected. Options are not discussed in depth and the routine practice takes precedence over informed choice. We encourage our clients to include their plans for placental birth in their birth plan and spend the time discussing the options well before they give birth. Sara Wickham and Nadine Edwards have written a really comprehensive but accessible guide to birthing your placenta, which we would highly recommend reading during pregnancy. Getting informed will prevent you from having to make last minute decisions about how you wish to birth your placenta with a midwife or obstetrician you have never met before, just at the moment when you should be basking in the glory of having birthed your baby!

How Continuity of Care Supports a Physiological Placental Birth

This brings me onto how continuity of care with an independent midwife could enable you to have a truly physiological birth of the placenta. When you have an independent midwife who provides continuity throughout your pregnancy, labour and birth they are able to support you in your choices, without being bound by hospital policies. This can go a long way to preventing the overuse of non evidence based medical interventions and enable true physiology to run its course. In addition, as independent midwives, we have time – time to spend with you and go through all your options in depth. We get to learn what makes you tick so that when you tell us something is changing, be it through your facial expressions or body language, we’re able to interpret what may be going on for you and anticipate ways we can support that. This is key in supporting physiological birth of your placenta and preventing adverse outcomes like excessive bleeding. This means that if you wish to have a physiological birth of the placenta it is a good idea to have the same midwife for this part as for all the other parts that have gone before (antental, early labour, labour and birth!). True continuity of carer is highly unlikely to achieve if birthing in a hospital setting, and this is worth thinking about when considering your options for placental birth.

“There are a few key elements to facilitating the physiological birth of a placenta. There are not set tasks attached to providing care, unlike in active management. Instead we take our cue from the woman or birthing person” Soliman, 2024

The earlier you book an independent midwife the more time you have with them. Having a homebirth with an independent midwife who you know and trust has been shown to support physiology and prevent adverse outcomes, so is a key way of preparing for a physiological birth of the placenta. As independent midwives, we see birth as a continuum whereby this experience is not disturbed by a changeover of staff in a hospital, or transferring rooms for different ‘stages’ of labour and care is provided by someone you’ve never met. These routine aspects interfere with the establishment of a safe, warm and protective birth space – all things needed to support physiology in labour and birth.

Top Tips for Supporting a Physiological Placental Birth

• Keep lighting low
• Stay warm with extra towels and blankets
• Have skin to skin with your baby +/- breastfeeding
• Healthcare providers and birth partners should keep voices low
• Leave the cord to pulsate – there is often no immediate need to keep checking the cord, especially if you are doing optimal cord clamping
• Let your midwife know what you’re feeling, if you feel the need to!

Learn more…

Read: Birthing your placenta: the third stage of labour by Dr Nadine Edwards and Dr Sarah Wickham

Listen: Episode 24 of the Great Birth Rebellion – Placental Birth

Watch: Born at Home – find your local showing here

References

Soliman, N. (2024) Physiological Birth of the Placenta. The Practising Midwife 27(2), pages 12 – 15