Natural (“Physiological”) Third Stage in Child Birth
You may have heard about the controversy regarding what the best time is, to clamp and cut the umbilical cord once an infant is born. And you may have also heard about delivering the placenta the natural way, by letting it detach and drop down all on its own, without anyone pulling on the cord.
Both of these, cord-clamping and delivery of the placenta, are part of what medical professionals call the “third stage of labor.” The first stage starts with the first contraction and ends when your cervix is fully dilated; the second stage is the birth of the baby; and the third stage is from birth of the infant to delivery of the placenta shortly after.
A woman can choose to have a physiological — or natural — third stage, or an “actively managed” one. It is essential that you discuss with the health professionals who will be assisting you in the birth of your baby the specific ways that you want things to be done. You must find providers who are comfortable and experienced with the type of birth that you want for your baby.
A physiological or natural third stage means:
- You will be given no drugs to stimulate the uterus to contract into a smaller size after the baby is born
- The infant’s umbilical cord will not be clamped immediately after birth, like it always is in regular hospitals (unless the mother specifies otherwise). The midwife or attendant will instead allow the umbilical cord to continue transferring blood from the placenta into the baby; the cord will be allowed to cease pulsating before it is clamped and cut. Baby may be placed at or below level of the uterus, to insure that gravity helps get the blood into infant
- Your uterus will be allowed to close in on its own; the shrinking womb will naturally cause the placenta to start peeling away from the wall of your uterus, until eventually, it drops into the vagina; you are then able to push it out. Midwives who assist in natural births recommend that moms use the force of gravity to their advantage here: instead of lying down horizontally to push out the baby and the placenta, you may be advised to assume a squatting position for both events, as that will make it easier for them to come out. Or the midwife may recommend that you be in an upright position (sitting up), if you are not squatting
Using Skin-to-Skin Contact with Baby to Help Placenta Come Out
Another way in which you can use nature to speed delivery of the placenta is by holding your baby immediately after birth, while s/he is still attached to your placenta through the umbilical cord. Skin-to-skin contact with your newborn promotes colonization of the baby’s body with your bacteria — the right kind of bacteria for him or her, which will help guide the developing immune system, as well as prevent allergies and skin conditions later on. But skin-to-skin will serve another important purpose during this stage: it will cause your body to secrete more of the hormone oxytocin, the “love” hormone, as doctors call it, into your blood. That will not only make you feel warm and loving, but it also will cause the uterus to shrink, thus helping to stimulate delivery of the placenta. Breastfeeding also boosts oxytocin levels in your blood — but your baby may or may not be ready to try it just yet. If not, there’s no need to push it. Simply enjoy each other’s closeness.
In a natural third stage, the infant’s cord will be clamped and cut once the placenta is delivered, or at the very least, when the cord stops pulsating and the baby has drawn a few breaths.
Once the placenta comes out, the person attending you will examine it to make sure all of it is out of your womb.
What Is a Managed Third Stage?
An actively managed third stage of labor is when drugs may be used to stimulate stronger uterine contractions after the baby is born, thereby prompting a faster delivery of the placenta. The newborn’s umbilical cord will likely be clamped and cut within a few to 20 seconds after birth; minutes later, the midwife will gently pull on the cord still attached to the placenta — this is known as “controlled cord traction” — to bring out the placenta.
Even if you have a managed third stage, you can still request that the attendant wait to clamp and cut your baby’s cord; many conventional medical doctors are now advising midwives and other doctors to wait at least about 60 seconds before clamping and cutting the cord, to allow more transfer of blood into the baby.
Again, it is necessary that you discuss with the people who may be helping you give birth the specifics of how you want the process to be done, to determine whether the health professionals and the facility you have in mind would be willing and able to carry out your wishes.
Be advised that your provider may recommend a managed third stage if:
- There were complications in your pregnancy or labor, such as an assisted birth or a caesarean section
- You had heavy bleeding during pregnancy or labor
- You are having more than one baby
- You had a low-lying placenta
- You got an epidural or episiotomy
A natural third stage and a managed third stage each takes about the same length of time: a little more than 10 minutes from the time the baby is born to when the placenta comes out. But on occasion, a natural third stage may take about an hour.
Advantages and Disadvantages of Natural vs. Managed Third Stage
Many health professionals believe that a managed third stage reduces the likelihood of post-partum hemorrhage (PPH) in the mother, which is the number one cause of maternal death globally, according to the World Health Organization. Excessive heavy bleeding could also result in the mother becoming anemic later on.
Some studies, however, have found just the opposite: a managed third stage actually multiplies the risk of PPH in mothers, compared to a natural, holistic approach. Some natural birth experts believe that while a natural third stage is optimal and will reduce the risk of PPH in a setting designed for natural births, a managed third stage may lower the risk of PPH in a setting where natural births are not performed and where interventions are the norm.
Natural birth advocates believe that there are several essential advantages for both mother and infant in having a natural third stage:
When the cord is clamped and cut too soon, a baby is robbed of a sizable amount (up to half, according to some estimates) of the oxygen-rich blood that nature intended for the infant to receive. A newborn only has about 8-12 oz of blood in its body, depending on the size of the baby. So, even a couple or a few ounces of decreased blood volume could impact the infant’s health negatively.
A baby whose cord is clamped and cut right after birth will on average weigh slightly less than one who got delayed cord-clamping. The difference reflects the amount of placental blood that did not finish pulsating into the infant once the cord was clamped. Health professionals who perform natural childbirths point to the irony that babies who are born prematurely or do not start breathing on their own right away are that much more likely to get the umbilical cord clamped and cut quickly — even though they would benefit the most from delayed cord-clamping, which would allow more oxygenated placental blood into their bodies. This blood would help tide them over longer, until resuscitation was done or breathing was established.
Another big point to consider in delayed cord-clamping is that when the infant draws its first breath, the lungs expand for the first time; that automatically draws in blood from the umbilical cord — rich, nourishing blood filled with cells that will travel to the baby’s bone marrow and transform into different blood-making cells. This placental/cord blood will bathe the child’s lungs for the first time, establishing the lung exchange of gases. When the cord is cut too early (before the baby takes a few breaths), blood will travel to the lungs from other areas, which can result in a blood shortage for the infant, a greater likelihood of breathing difficulties, and a higher possibility of iron-deficiency anemia later on. These risks are especially heightened in babies who have other vulnerabilities, such as prematurity.
A further important advantage in waiting to clamp the cord is that the placenta empties out its blood content more fully, shrinking the organ’s size, which will cause it to more readily detach from the uterine wall. A swift, clean detachment is harder for a placenta that is still engorged with blood. In addition, a fuller placenta gets in the way of the uterus shrinking like it now needs to do to help collapse and close blood vessels that were carrying blood from the mother to the umbilical cord.
According to Dr. Sarah Buckley, a New Zealand family physician, author and advocate of natural birth, during a natural third stage of labor, when the placenta is in the process of gradually detaching from the uterus as the latter contracts, each contraction sends fresh blood into the baby, who is still attached to the umbilical cord. Some of the cord blood returns to the placenta between contractions. Dr. Buckley believes this indicates that each infant gets an optimal, though not equal, amount of blood as the placenta is detaching. She believes that in this way, nature gives each baby the right amount of blood s/he needs.
With respect to the cord blood returning to the placenta between contractions, if the cord is clamped before the placenta naturally detaches, some of the baby’s blood will be included in that blood returning to the placenta from the cord. Because there is no blood going from mother to baby anymore, that blood belonging to the infant may get “trapped” in the placenta and make its way into the mother’s circulation as the placenta detaches. That feto-maternal hemorrhage (FMH) raises the risk of blood group incompatibility in future pregnancies. When the infant’s blood enters the mother’s bloodstream, it triggers an immune reaction, which can be reactivated in a subsequent pregnancy. The reaction can destroy the blood cells in the new baby growing in the uterus, resulting in anemia or even death to the infant.
Some Other Points to Consider…
Another issue on which natural birth advocates agree is that the atmosphere for a successful natural birth, as well as a natural third stage, should be made as soothing and calm as possible. No unnecessary interventions or various staff or family scurrying about.
When mom is finally holding her newborn in her arms, the two of them should be allowed to take it all in, in a tranquil, relaxed environment. It is important for both mother and child to reduce stress hormones which peaked for both during the birth of the infant.
For the mother, increasing oxytocin levels, while decreasing adrenaline levels, will help produce stronger uterine contractions, which will aid in expelling the placenta naturally. It is also important to think of what the baby just went through, a very traumatic experience, and to allow the mother to give her infant skin-to-skin nurturance and other signs of love, as she speaks to her baby in soothing, soft tones. The infant may make the first attempts at breastfeeding, as the two enjoy the sheer magic of their new lives.
By Cynthia Sanchez. A graduate of the University of Washington, Cynthia has extensive experience writing about health and wellness topics for different media.