What the third stage is

NICE defines it as "the time from the birth of the baby to the expulsion of the placenta and membranes". It also opens the section with an instruction about atmosphere rather than technique: teams should "recognise that the time immediately after the birth is when the woman and her birth companion(s) are meeting and getting to know the baby", and ensure any care or intervention is sensitive to that and "minimise separation or disruption of the mother and baby."

The two options, defined

NICE describes both as packages of care, not single decisions.

Active management comprises "routine use of uterotonic drugs", "cord clamping and cutting of the cord", and "controlled cord traction after signs of separation of the placenta".

Physiological management comprises "no routine use of uterotonic drugs", "no clamping of the cord until pulsation has stopped, or after delivery of the placenta", and "delivery of the placenta spontaneously or by maternal effort."

The NHS describes the same two as "active — when you have treatment to make it happen faster" and "physiological — when you have no treatment and this stage happens naturally", and notes your midwife should explain both while you are still pregnant or in early labour.

The numbers

NICE publishes a side-by-side table so this can be a real decision rather than a preference stated in the dark. Comparing active with physiological management, per 1,000 women:

Haemorrhage over 500 mL: about 68 with active management versus about 188 with physiological — about 120 fewer per 1,000.
Haemorrhage over 1 litre: about 13 versus about 29 — about 16 fewer per 1,000.
Need for blood transfusion: about 13 versus about 35 — about 22 fewer per 1,000.
Postpartum anaemia (haemoglobin under 9 g/dL): about 30 versus about 60.
Need for further uterotonics: about 47 versus about 247 — about 200 fewer per 1,000.
Side effects (nausea and vomiting, headache, hypertension, readmission for bleeding): about 186 with active management versus about 90 with physiological — about 96 more per 1,000.

NICE's second table lists what did not differ between the two: retained placenta beyond one hour or needing manual removal, antibiotics for bleeding up to six weeks, satisfaction with third-stage management, and feeling in control during labour.

The NHS summarises the trade-off in a sentence: active management "speeds up the delivery of the placenta and lowers your risk of having heavy bleeding after the birth (postpartum haemorrhage), but it increases the chance of you feeling and being sick. It can also make afterpains ... worse."

Your choice, on the record

NICE's position is that active management is advised, and that a request for physiological management should be respected. It says to "advise women that active management of the third stage of labour is associated with a lower risk of a postpartum haemorrhage or blood transfusion", and that if a woman requests physiological management, teams should "discuss her level of risk so she can make an informed decision" and "support her in her choice." The decision agreed with you is documented.

What active management involves in practice

The drug goes in as your baby is born. NICE specifies, for active management after a vaginal birth, "10 units of oxytocin (by intramuscular injection), 5 units of oxytocin (by intravenous injection), or 5 units of oxytocin plus 500 micrograms of ergometrine (by intramuscular injection) immediately after the birth of the baby and before the cord is clamped and cut."

If you are having a caesarean, NICE recommends carbetocin by slow intravenous injection instead.

There is a conversation to be had about which uterotonic. NICE says oxytocin plus ergometrine "may be more effective than oxytocin alone at reducing the risk of postpartum haemorrhage", is advised where there are risk factors for haemorrhage, but "is more likely to lead to nausea and vomiting compared with oxytocin alone". It is contraindicated in severe hypertension, pre-eclampsia, eclampsia, and severe cardiac, hepatic or renal disease. NICE also asks that antiemetics be offered to women having oxytocin plus ergometrine.

The cord is then clamped and cut, and once there are signs the placenta has separated, the midwife applies controlled cord traction. The NHS describes the outcome: this "usually happens within 30 minutes of your baby being born."

What physiological management involves

No injection. The NHS: "The cord is not cut until it has stopped pulsing. This means blood is still passing from the placenta to your baby. This usually takes around 2 to 4 minutes." Then, once the placenta has come away, "you should feel some pressure in your bottom and you'll need to push the placenta out. It can take up to an hour for the placenta to come away, but it usually only takes a few minutes to push it out."

The HSE describes the same thing from the midwife's side: when you start to feel pressure, she checks for signs the placenta has separated, and "you can help the placenta to separate by starting to breastfeed." You are then encouraged into an upright position, and "the placenta usually comes out with a few gentle pushes from you."

When the plan changes mid-course

NICE gives two triggers for switching from physiological to active management: haemorrhage, or "the placenta is not delivered within 1 hour of the birth of the baby." It also says a switch should be offered if you simply want to shorten the third stage. The NHS confirms you can change your mind "at any time during the 3rd stage of labour."

The HSE lists when a midwife may offer the oxytocin injection even if you planned otherwise: if the placenta is not separating, if bleeding is heavier than normal, or if you had an induction, epidural, assisted birth or caesarean.

Prolonged third stage and retained placenta

NICE defines a prolonged third stage as one "not completed within 30 minutes of the birth with active management or within 60 minutes of the birth with physiological management."

If the placenta is retained, intravenous access is secured. NICE tells teams not to use umbilical vein agents and not to use intravenous oxytocic agents routinely, but to give them if you are bleeding excessively. If there is concern about your condition, a vaginal examination is offered to assess whether manual removal is needed, with the warning that "this assessment can be painful" and advice to have analgesia — and if you report inadequate pain relief, the examination stops immediately.

Manual removal is never done without an anaesthetic: NICE says "do not carry out uterine exploration or manual removal of the placenta without an anaesthetic." If you are not already in an obstetric unit, transfer is arranged.

The NHS adds practical first steps that come before any of this: breastfeeding your baby as soon as possible after the birth "can help your womb contract and push the placenta out", and your midwife may ask you to change position, for example to sitting or squatting.

What is being watched

NICE asks for two observations to be recorded in the third stage: your general physical condition "as shown by your colour, respiration and your own report of how you feel", and vaginal blood loss. If there is a postpartum haemorrhage, retained placenta or collapse, observations become frequent and transfer to obstetric care follows.

The NHS explains the reason the oxytocin injection exists at all: postpartum haemorrhage sometimes happens "because your womb doesn't contract strongly enough after the birth", and can also happen because part of the placenta has been left behind or because of infection in the womb lining.

Delivering the Placenta