A woman’s third stage of labour is an extremely precious and important milestone, as it marks her transition into motherhood (Fry, 2007). The significance of this stage has been recognised since the time of the ancient Greeks where Aristoteles (384-322 BC) suggested the use of weights around the umbilical cord or causing a woman to sneeze to assist the delivery of the placenta (Gulmezoglu & Souza, 2009). However, over the last decade or more there has been great debate over the best and safest management of a woman’s third stage of labour (Stables & Rankin, 2011).
This essay will look at the elements that make up physiological or expectant management of a woman’s third stage of labour as well as discuss associated issues. Johnson and Taylor (2011) describe the third stage of labour as the period from when the baby is delivered to when the placenta and membranes are expelled from the mother. Harris (2011) expands upon this definition by outlining three separate phases – latent, contraction/detachment and expulsion. The latent stage is characterised by the period between the delivery of the baby and when the placenta begins to separate from the mother’s uterus.
In the contraction or detachment phase, the myometrium under the lowest part of the placenta contracts and a “shearing” occurs which causes the placenta to tear away from the decidua. Finally, in the expulsion phase as the uterus contracts, the membranes also detach and along with the placenta, moves into the vagina to be delivered (Johnson & Taylor, 2011). German gynecologist Johann Friedrich Ahlfeld (1843-1929) was the first to propose a “hands off” approach to third stage labour, which subsequently contributed to the expectant or physiological management methods used today (Gulmezoglu & Souza, 2009).
Fry (2007) states that it permits the woman to deliver the placenta and membranes on her own accord in a spontaneous manner leaving the umbilical cord in tact until pulsation is no longer felt. This process may last between 5 to 30 minutes, but may take as long as an hour (Stables & Rankin, 2011; Hastie & Fahy, 2009). To support the woman in a natural third stage labour, Hastie and Fahy (2009) suggest the use of a ‘Midwifery Guardianship’ model that includes elements such as skin-to-skin contact between mother and baby as soon as possible after the birth, a safe and encouraging environment, mother and baby kept warm, no cord traction or undal interference, self-attachment breastfeeding and sitting in an upright position to allow gravity to assist in delivery of the placenta. As previously outlined, an important issue impacting upon the successful implementation of this stage is the physiology of the woman and her environment, and is referred to by Fahy et al. (2010) as “holistic psychophysiological care”. This places an emphasis on the right conditions for the optimal functioning of a woman’s physiology, including feeling safe, warm and secure.
If this fragile balance is interrupted, an increase in postpartum haemorrhage (PPH) or other complications may occur (Buckley, 2004). If a woman is feeling stressed or fearful in third stage labour, this may activate the sympathetic nervous system, triggering the release of catecholamines which in turn inhibits the release of oxytocin – an important hormone that contracts the uterus and assists in the progress of the third stage of labour (Gyte as cited in Hastie & Fahy, 2009).
On the other hand, if a woman feels warm, calm and safe, the woman’s parasympathetic nervous system is in control and allows for the release of oxytocin upon the smell, touch and feel of her baby and ultimately that strong uterine contraction needed to facilitate a physiological third stage of labour and a state of haemostasis (Hastie & Fahy, 2009). However, according to Walsh (as cited in Fry, 2007) support of physiological third stage is becoming less common.
The medical-model of care has had a large impact on women’s choices and support of physiological third stage has been replaced by a “risk mitigation” approach known as active management (Fry, 2007) that encourages prophylactic oxytocic drugs, clamping the cord early after birth and use of controlled cord traction (Royal Australian and New Zealand College of Obstetricians and Gynecologists [RANZCOG], 2011).
Although recommended by a number of professional bodies including RANZCOG and the World Health Organisation (WHO), some evidence does suggest that the use of these measures, especially the use of prophylactic oxytocic drugs, has an adverse affect on the woman’s normal physiological functioning during this stage and may result in complications such as high blood pressure, nausea, vomiting and headaches as well as higher rates of postpartum eclampsia and even cardiac disorders (Hastie & Fahy, 2009; Harris, 2011).
Another issue hindering the use of physiological third stage labour is the concern of excessive bleeding and PPH. According to Jangsten, Mattsson, Lyckestam, Hellstrom, and Berg (2010), third stage labour is extremely dangerous due to the risk of severe bleeding or PPH. Information from RANZCOG shows that PPH is the major factor that results in maternal morbidity and mortality within Australia and New Zealand with an incidence rate between 5 and 15 percent (RANZCOG, 2011).
RANZCOG also state that the active management approach should be recommended to women to reduce the risk of PPH. Johnson and Taylor (2011) and Kashanian, Fekrat, Masoomi, and Ansari (2008) note that studies have found that expectant third stage management is associated with a high blood loss (excess of 500mL, and in some countries 1000mL) however the degree to which the active method improves the woman and baby’s well-being in a specific setting, has according to Soltani (2008), not yet been investigated in a holistic manner.
Some evidence proposes that as long as the blood loss is not excessive, and the woman is stable, it may be a physiological loss with which the woman can bear (Johnson & Taylor, 2011). This is further supported by an Australian retrospective cohort study conducted between 2005 – 2008 on 3075 low risk women in a Newcastle tertiary maternity hospital that showed expectant management in this case did not correlate to PPH. Three hundred and forty seven or 11. 5% of the women actively managed encountered PPH whereas only 7 or 1. % of the women who experienced holistic psychophysiological management experienced PPH (Fahy et al. , 2010). Delayed umbilical cord clamping is another important element of physiological management (Mercer, Skovgaard, Peareara, & Bowman, 2005). Mercer’s nucal cord management review of newborns outlines a cardiac output of 50% must go through the baby’s lungs to commence gas exchange. Before the baby is born, approximately 30% of its blood capacity comes from the placenta.
If the cord is clamped prematurely, there will be 20ml per kilogram less blood delivered to the lungs compared to a baby whose cord was clamped at a later time (Mercer et al. , 2005; Bair & Williams, 2007). According to Johnson and Taylor (2011), and Harris (2011) clamping of the cord also has an effect how the uterus contracts and retracts. If the cord is clamped too early, blood flow is prevented from reaching the baby (Bair & Williams, 2007). This doesn’t allow for the size of the placenta to decrease thus making the process of separation much slower thus increasing the risk of heamorrhage.
While it is difficult to discuss all aspects and issues regarding a woman’s third stage of labour, it is important however to remember that midwives have a responsibility to enable informed choice for the woman and must be confident in their knowledge and skills to support her choice regarding the management of her labour – physiological or otherwise. The key points for this essay are: * Increased debate over best way to manage third stage labour. * Third stage – period when the baby is born up to delivery of placenta and membranes (latent, contraction/detachment and expulsion phase). Physiological management – woman delivers the placenta and membranes on her own accord. * Environmental factors can impact on physiological third stage. * Key aspects of physiological care are skin-to-skin contact, self-attachment breastfeeding, delayed cord clamping, fundus is left alone, no eterotonic drugs. * Decline in use of physiological management due to medical-model of care. * Despite evidence that physiological management causes increased risk of PPH, extent to which alternative improves woman and baby’s health has not been investigated holistically.
