The idea of active management of the third stage has never sat right with me. Even before I developed my interest in natural childbirth. When I was pregnant with my daughter, I was taking one of the hospital classes I talk about that are not so great. The nurse who was teaching the class told us that after our babies were born, we would be getting pitocin in our IVs to help the placenta come out and help the uterus clamp down to put pressure on the placenta site to prevent too much bleeding. I asked if you can decline it and she acted like that would be a stupid thing to do, because why would you want to risk bleeding too much and before we had it a lot of women died from hemorrhage.
It just didn't seem right to me. I didn't like the idea of having a medication to prevent a complication that only might happen. This was part of my reasoning behind changing providers and hospitals. My CNMs told me that with an unmedicated birth, third stage pitocin is often unnecessary, so my birth plan said I didn't want it unless I started to hemorrhage. I ended up being induced with pitocin for that birth anyway, so it didn't matter.
When I moved to a new area while 3 months pregnant with my son, I called the hospital where I was planning on birthing for a recommendation for a provider who would be supportive of natural birth (they recommended Dr. I., who was awesome) and the nurse and I talked about the policies. She said that if I really didn't want an IV, they could do the postpartum pitocin as an IM injection instead and told me that in her 10 years as a nurse, she had never seen a woman not get pitocin after giving birth. When I met with Dr. I., I talked to her about this, and she brought up that breastfeeding really should work just as well as pitocin. She said she would support trying breastfeeding first.
So, then, I had an unmedicated birth, but they had to take my baby to the warmer to give him oxygen. Dr. I. waited until the placenta was out to see how much I bled, but it was too much, so I got both pitocin and methergine--I think it is possible that doing it later is why I needed both.
I wondered if perhaps I'm just a "bleeder" and will need pitocin for all of my births. I don't have a problem with it if it is actually necessary. Then Gloira Lemay shared with me an Australian article called Optimising psychophysiology in third stage of labour: theory applied to practice. I read the full article (link is to the abstract). I believe these authors are on to something, and I would love to see more research on this topic. You can read an interview with one of the article's authors at the Science and Sensibility blog.
The basic idea is that studies of "active management" and "expectant management" haven't really studied truly physiological third stages. The authors theorize that in order to produce the oxytocin surge necessary to help her uterus contract sufficiently to avoid hemorrhage, the mother needs to focus on her baby, holding him skin to skin, in a calm environment with little distraction. This is certainly different than how my 3rd stage was with my son, and I think it is likely pretty rare in a hospital setting.
In natural childbirth education, and especially with hypnosis, we try to help women produce the right natural chemicals in their bodies to promote smooth (and even comfortable) birthing in the first and second stages (though the second seems to be more difficult for some of us). There is scientific evidence that the mind and body are connected and our thoughts and feelings have direct effects in our bodies (the research of Dr. Candace Pert on neuropeptides is one example). We strive for a relaxed, comfortable state of mind to promote oxytocin and endorphins in the first two stages--it makes sense that the same sort of mental state would be necessary for a natural third stage. Third stage is still part of birth, and it's important for both women and their caregivers to recognize this.
The belief of the L&D nurses I have spoken with seems to be that an unmedicated third stage with a small amount of bleeding would be an exception. It seems to me that under the right conditions, a gentle, hands-off approach could make postpartum hemorrhage the exception rather than the rule. According to Gloria Lemay, it works.
In order to accomplish a natural third stage, separation of mother and baby must be avoided whenever possible. This is easy if you don't cut the cord right away. Check out Navelgazing Midwife's recent post on the gross practice of using shoestrings to clamp the cord in unplanned out-out-of-hospital births. And for more on keeping mother and baby together, check out the recently posted Healthy Birth Blog Carnival #6: MotherBaby Edition
be sure to check out my new follow up to this post: Physiological Third Stage, without the "as long as"