Thinking about third stage…

Recently I have heard three stories about women who have had normal spontaneous (not induced) labours and births and then big post-partum haemorrhages after a physiological third stage in hospital. One woman needed a transfusion of several units of blood and was transferred to Melbourne for intensive care.

I feel compelled to explain a few things about the third stage of labour to help make it safer and hopefully prevent similar stories for other women.

The Bendigo Positive Birthing group and myself, as a midwife, encourage women to educate themselves about labour and birth: to know as much as you can about the best ways to help yourself achieve a positive birth. Many women want to experience natural birth, they want to give birth without drugs and medical interventions. Women know their bodies work well. Women want to welcome their babies gently, with love, using their own powerful resources.


One of the things that women realise is that their bodies have finely tuned hormones and physiological processes that work together throughout the birth process, including the contraction of the uterus and subsequent birth of the placenta (third stage). During natural third stage the mother is having the physical experience of the post birth release and the emotional, tactile and hormonal experience of meeting her newborn. These complex interactions lead to the birth of the baby’s placenta.

With a physiological or natural third stage, the mother is supported to greet her baby in her own way and her own time. The baby will naturally be skin to skin with the mother. The mother is not be disturbed so that she can remain in her labour state of heart and mind. No one is to interfere with the baby or mother. The cord remains untouched. The midwife should be sitting, according to Michel Odent, “intelligently knitting”. The room should be quiet and calm, with low lights. Eventually the mother will birth the placenta easily, with minimal blood loss. This is because when the mother is undisturbed, warm and supported, her body works best.

This is a physiological (natural) third stage of labour.


Hospitals have policies which guide them in the care they give their patients and there are policies specific to various birth practices. Hospital policy for the standard management of third stage of labour is termed active management of third stage and will typically include an injection of synthetic oxytocin immediately post birth and controlled cord traction (careful pulling on the cord) until delivery of the placenta. This is the normal care hospital staff are trained to give. They give the oxytocin injection to facilitate the delivery of the placenta and to prevent a post-partum haemorrhage.

It is normal to have some bleeding immediately after birth, 150- 350mls is usual. A postpartum haemorrhage is defined as more than 500-600mls. Post partum haemorrhage is common (According to the Australia’s Mothers and Babies Report, in 2012 135.7 per 1000 women in Victoria had a PPH).

You may decide you do not want this standard care or active management of third stage. However my concern is that if you decide you want a more natural birth in a hospital setting, you might therefore decline the oxytocin injection following birth; however a physiological third stage is more than just declining to have the oxytocin injection. A physiological third stage means that no one touches the cord, that you are quietly and unobtrusively supported to meet your baby and stay in your labour state. That you are kept warm and feel loved and respected by those around you.

A physiological third stage is dependent on those around you understanding and knowing how to support natural processes.

Many hospital staff are not familiar with how to support a physiological third stage and may mistakenly believe that it means just opting not to have the injection. It is more than that. If staff comply with your wish to not have the post birth oxytocin but then continue with the other standard practices of actively managed third stage this will interrupt the complex interactions that lead to the natural birthing of the placenta and lead to increased risk of haemorrhage.

This means if anyone disturbs the initial meeting of you with your baby, or requires you to use your cognitive mind rather than your emotional instinctive mind (such as talking or asking questions), or if anyone applies controlled cord traction (pulling on the cord) you may be likely to lose more blood than with either a physiological or an actively managed third stage.

In conclusion I suggest that if you want a physiological third stage of labour it is up to you to make sure that your care providers understand and are familiar with how to support you to birth your baby’s placenta and how to support the natural processes involved. If your care providers do not support or understand physiological third stage, and are not prepared to educate themselves in supporting natural, unfortunately it may be safer to accept the oxytocin injection post birth.

The following is one of Sarah Buckley’s favourite quotes from Dutch professor of obstetrics G. Kloosterman,

“Spontaneous labour in a normal woman is an event marked by a number of processes so complicated and so perfectly attuned to each other that any interference will only detract from the optimal character.

The only thing required from the bystanders is that they show respect for this awe-inspiring process by complying with the first rule of medicine–nil nocere

[Do no harm]”

The following links will help you and your care providers to understand more about physiological third stage and how to best support natural processes:

Hilder L, Zhichao Z, Parker M, Jahan S, Chambers GM 2014. Australia’s mothers and babies 2012.

Perinatal statistics series no. 30. Cat. no. PER 69. Canberra: AIHW

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About the Author:

My husband Louis and I have two lovely teenagers. I am a midwife. In 2013 after 25 years in midwifery, I finally followed my dream to independent practice as a homebirth midwife. The heart of my midwifery practice is respect for women as individuals, whose pregnancy and birth experiences benefit from knowledge, compassion, security and encouragement. My privilege is to be with women and their families, as they recognise their strength and ability to grow and birth their babies.

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