Thursday, June 24, 2010

A Natural Third Stage?

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"


  1. I had my first birth in a hospital with midwives (no meds or interventions). I have a distinct memory of the nurse coming over with the pitocin afterwards and the midwife saying, no, she doesn't need it. I had my second baby at home -- again, no pitocin, not much bleeding. Maybe I'm just not a bleeder, but I think you are onto something.

  2. This is fascinating--I'd never heard of the Pitocin-to-expel-placenta thing; I birthed twice at the hospital, but with midwives in a fairly natural-birth-supportive environment, and each time it was a simple matter of, "Okay, I need you to push out that placenta now." "whine whine I'm tired it hurts." "Just give it a little push, see if you can do it." "okay, FINE, I'll do it" and I pushed and it slid out and that was it. I'd never even heard of this idea that women without meds will hemorrhage.

    (With my first baby, he was whisked off to the nursery right away, because he was premature, and for the second she was born in the tub and I got lots of cuddle time right away...)

  3. I had the needle with my first because I'd had pitocin to augment my labour and an assisted delivery anyway. They were fully hands-on by that point.
    With my 2nd, it was a home birth and it took 4 hours and 45 minutes for the placenta to separate and be delivered, but I had full skin to skin contact with bub the entire time, who was breastfeeding a lot, and my uterus contracted the whole time and my bleeding was very minimal. I think there's something to that research too.

  4. This is great, Brittany. I really appreciate you sharing the link! I'd love to see that PDF. :-)

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  6. I am a former labor/delivery RN myself and would share that the births I was a part of that did not require pitocin, methergine or hemabate after delivery were most frequently midwife attended, in a dim room and where the mother kept the babe skin to skin for an hour. Backing up the research and statements here. The other thing of note though is that many MD's wouldn't allow a pt to labor without an IV and pit hanging right after delivery so we'd never know what the outcomes would have been if wed left them alone, but I'd suspect not as good. Unfortunately the birth I describe above would be a tough birth to have in many hospitals (not if I were your nurse, but those kind of nurses are the exception anymore)... I'm about to have a HB myself though and really enjoyed reading this. Thank you. (removed the first post accidentally, sorry)

  7. with my first i had an epidural/forceps delivery and so of course i had the obligatory pitocin in there somewhere. the rest (6 full term pregnancies) i had midiwves out of hospital and home and havent ever needed pitocin . they watch my bleeding very closely after birth and dont rush the 3rd stage. i will say i read in a book about eating right for your blood type the author said people in general with type O blood naturally have less clotting factor and are more prone to be bleeders . he recommended to anyone type Os that if they were having surgery or childbirth to up their intake of "chlorophyll" which is high in vitamin K . ironically id taken this supplement with all six but i was taking it for low iron. :). i did have all that yummy skin to skin contact after the 6 births and so im sure that helped too. i just found the possible vit k link interesting .

  8. Busca--I sent you the PDF of the full article by e-mail.

    Joni--Thanks so much for sharing how your experiences as a nurse support these theories!

    Anonymous--I'm type O as well, so that is really good to know! It makes a lot of sense to me that nutrition would influence the clotting factors in the blood, which would affect the risk of hemmhorrage. I also have a history of low iron, so increasd chlorophyll intake would benefit me all around. Thanks for the info!

    I am working on a follow up to this post with a link to a post about timing of cord cutting and babies who need "help" from an awesome midwife's blog I just started following recently.

  9. Brittany,
    I can tell you from my own experience that there truely is a connection between the need to know our babies are OK and the release of our placentas. My 5 baby was born in a hospital(a UC transfer) after his birth I refused pitocin. The doc agreed to let me wait 1 hour before she insisted I get the pitocin. I agreed. My placenta has never taken longer than 20 mins to be birth (at home). Even after a very large dose of pit my placenta would not release. I refused to let her do any type of traction on the cord. I also refused to let the nurses give my baby formula and insisted that I be allowed to nurse him. It wasn`t until I nursed him and had a chance to talk with him, when I knew he was OK, that I felt relieved and calm, and my placenta came out just fine, intact.
    I have read some where, can`t remember where now, that our bodies won`t release the placenta until we know everything with our babies is OK and good. I am convinsed this is the case with my story. Even the pit couldn`t over ride my mothering instincts in this case. God created our bodies to birth and this just another wonderful part of that whole process.-Kristi W.

  10. Active management of ANY stage of labor is unnecessary and causes problems. (I'm not referring to a true emergency case.) How did humans manage to survive for so long without pitocin?!