30 Minute Third Stage

Student supervisor wrote:

Has anyone been involved in the development of third stage guidelines.
As a student supervisor of midwives I have ending up volunteering myself
for this task and need some guidance and info. Anything would be good.
______________________________________________________________

Jessica (midwife) wrote:
I get the woman into squatting as soon as possible- usually 4 minutes
after birth and she pushes it out in squatting.
This is usually on the floor, so it is stable.. I wouldn’t do it on a bed.
________________________________________________________

Gloria wrote: I can’t believe that a midwife would be getting a postpartum
woman into a squatting position and expecting her placenta out 4 minutes after birth.
This is a recipe for hemorrhage and prolapsed uterus!

If we need to have a time line for the placenta, it would be 30 minutes. The mother
has just given birth—she needs to luxuriate in the glorious feeling of
conquest, peace and joy at meeting her long-awaited newborn. Her uterus
responds to all the oxytocin love hormones by continuing to clamp down
around the placenta and safely bring it away from the uterine wall.

Here’s something I wrote on the subject that was published in Midwifery Today:

The 30-Minute Third Stage

by Gloria Lemay

I teach my student midwives in Canada the “30-Minute Third Stage.” This
means we don’t anticipate that the placenta will be pushed out for a
full 30 minutes after the birth of the baby. The “mood” of the birth is
maintained in the room, that is, no phone calls, no excited chatter, no
disturbance of the mother, lights low, mother and baby wrapped warmly
together skin-to-skin. We offer a warm herbal tea mixture with a
drinking straw and tell the mother, “This will help your placenta come
out smoothly, all in one piece.”

We don’t disturb the attachment that happens naturally or push sucking
at the breast. Many babies don’t want to feed right away, and usually
the family wants to enjoy undisturbed time to get to know each other.
More than sucking, it is the skin contact and little (or big) noises of
the newborn that make the uterus contract powerfully after the birth.

Almost one hundred percent of women look at the attendant at the
30-minute point and say, “I’m having more cramps,” “I’m feeling
pressure,” “Should it be hurting in my belly now?” or some other thing
that tells us the placenta is ready to come out.

We don’t look for lengthening of the cord, separation gush or any of the
usual observations. Our observations in the first hour after birth are,
“Is the mother bright-eyed?” “Does her face look beautiful and radiant?”
“Is she focused on her baby and enjoying this time with her child?” A
woman who is bleeding too heavily will look worried, have a lack of skin
sheen and may be asking someone else to hold her baby. These rare
occurrences indicate something is wrong and the mother needs immediate
attention either to stop bleeding or increase her blood sugars. There is
no need to pester the bright-eyed, radiant mother by fussing around with
pulse checks and BP readings. No routine Pitocin. With a stable mother,
there is no rush.

glowing face of the healthy postbirth woman

After the 30-minute point, most women push the placenta out by
themselves or with light traction. We have seen some third stages that
take more than two hours, but these are very rare. I have had years of
practice using this method and have attended hundreds of births, with
less than a 1% hemorrhage rate. Unfortunately, many midwives in North
America have the idea that the placenta should be out in 5–15 minutes.
In my view, this is a recipe for disaster.

Gloria Lemay

Added Dec. 2012 Some midwives in Australia published research which supports my methods.
http://www.academia.edu/191418/Optimising_psychophysiology_in_third_stage_of_labour_Theory_applied_to_practice

Added March 2013: This link will show you what I read that made me start doing 30 minutes of waiting after birth before even mentioning the placenta
http://www.glorialemay.com/blog/?p=891

49 thoughts on “30 Minute Third Stage

  1. Interesting timing on this post! I was just discussing this today with my midwife. I observed my first birth (as part of my childbirth educator’s certification) three weeks ago, and the doc ended up doing a D & C under general anesthetic to remove the retained placenta. But the doc and nurses were mashing the mom’s tummy and using traction from basically the moment the baby was born. It didn’t want to come and the OB even tried to remove it manually with only a local. I wonder if they had just let her alone for a few minutes if it would have detached on it’s own. ??

  2. In my first two births, the placenta came by itself about 10 minutes after the birth, no problem.

    In my third birth, the baby was born with the cord wrapped around her chest crosswise twice and around the neck three times. She did not breathe for about five minutes after birth. And it took over an hour for the placenta to come. My body knew that she needed the extra time, and the cord continued to pulse for quite some time afterwards as well.

    The assistant midwife asked me if I wanted “some help” (meaning traction on the cord) with the placenta at about the 30 minute mark, and I swear I have never had such a primal urge to bite someone in my entire life. I told her no, and glared until she retreated.

    Speaking merely from personal experience and only as a layman, I think guidelines beyond “use your common sense and judge based on what’s in front of you instead of some “should” statement” are a recipe for unnecessary intervention. JMO, natch, YMMV.

  3. Thanks for your comments. They add other dimensions to my post. I think that all the medical concern about retained pieces and retained clots are human-made problems. When women are medicated for birth, it creates a different body dynamic. When women give birth without drugs, things work more predictably from beginning to end of the birth process and beyond into the breastfeeding.

    Many women tell me that the nurse kneading and poking at their uterus after the birth hurt more than giving birth. In the days following birth, the midwife can ascertain if the uterus is descending back into the pelvis simply by inquiring how many pads the mother is using. The rule of thumb is that the mother shouldn’t be soaking 2 pads in one hour. In all my homebirth experience, I’ve never had a woman with heavy bleeding in the days following birth, therefore, I can confidently keep my hands off her belly.

  4. Unfortunately with my first birth my placenta was retained. All up I had the placenta in me for 12 hours. I had a homebirth and after an hour I had an injection of syntocin to help the placenta still nothing. This was the last resort after pushing, cord traction, squatting etc. I then tried for the next few hours to coaxe the stubborn placenta out – unfortunately after hours of waiting hospital was inevitable…..I was put on a drip which didn’t bring on anything and finally had a nurse use cord traction again to pull the placenta out. I really would love any info on natural remedies, having another homebirth, feeling confident that all will go smoothly but just want to have something prepared!!!

  5. Gloria… I came upon this as it was linked by a blog I follow. As a woman rapidly approaching the birth of her 4th child (and first homebirth, I’m 39 weeks now) and one who has had PPH issues in the past due to retained placenta and the use of various induction methods (primarily lots of pitocin), I found this post riveting and very informative. As a former labor and delivery RN, who has seen countless PPH’s, transfusions and hysterectomy’s as a result, I found this saddening in that women will rarely get this kind of experience in the hospital.

    In my experience the third stages I saw that were able to proceed without medical management were most commonly the ones that were midwife attended, in a dimly lit room and where mom and baby were allowed an hour of uninterrupted time. This comprised less than 5% of the births in the hospital where i worked. I left frustrated that I couldn’t affect change, couldn’t educate women and couldn’t fight stubborn Physicians.

    I’m looking forward to this kind of birth this time around :)

  6. Hi Gloria!
    Candice just told me that you will be coming to my blessingway! Thank you, it means a lot to me. I am going to a blessingway for my sister in law on Tuesday and have decided to put together a tea package for her. Candice told me that you have a wonderful tea recipe for postpartum with cramp bark (it is her 2nd baby) and cinnamon and I was hoping you could send it to me? I would really appreciate it!
    Thank you so much and see you soon!
    Kimberly

  7. recipe:
    2 heaping tbsp cramp bark
    1 cinnamon stick about 4″ long, broken in pieces

    Place the ingredients in a pot with 2 litres of water and bring to a boil. Turn down heat and simmer on a low boil for one hour. Barks need to be boiled in order to release their properties.

    Strain the tea and drink like medicine whenever the cramps/after pains are bothersome. Remember, the cramping is stopping you from bleeding too heavily so it is a good and healthy thing your body is doing.

  8. Interesting! I just had an unassisted homebirth 5 days ago, and the placenta took exactly 2 hours to release. I was getting annoyed with it by an hour and took three doses of Angelica tincture to help it let go, then used a bit of gentle cord traction while squatting over the toilet. There was a small clot that hadn’t wanted to come off, but otherwise it was fine, and I had very little bleeding.

  9. This sounds great to me! All my placentas have come out fairly quickly, but I like the idea of sitting quietly and enjoying baby without thinking about it until it annoys me.
    I attended a birth in the hospital last year (as doula) in which the mother had been induced and then the placenta would not release. Of course they want it out quickly and are not willing to wait. They manually went after it 2x and then did a D&C, but after reading online when I got home, I found it’s more common to have a “sticky placenta” when pitocin is used.

  10. Thanks for saying this. The longest time it took at any of my children’s births was 2 hours. We wondered why it was taking so long, but there were no problems, and I felt perfectly fine. It’s good to know there’s a range of normal.

    You want midwives to notice complications and respond. But equally dangerous are midwives who interfere when everything is okay. love, Val

  11. When I first began researching third stage on the way to Lotus Birth 30yrs ago I held third stage workshops where we explored our experiences and opened to new options for this stage of the process. Even in those early days sometimes someone would say ‘What if we didn’t cut the cord?’ We’d shrug and reply ‘Don’t know’ One of the hallmarks of these workshops was the untold stories of horrific experiences so many women had had often after given birth naturally and then finding themselves with people pummeling their stomachs, pulling on cords and reaching into their bodies causing excruciating pain. Others ended up in surgery under a GA. The rage and the hurt, the feelings of being abused all spilled out with the opportunity to reflect and talk about what had happened. Many were surprised at the depth of their emotions and afterwards would say that understanding where those feelings came from explained other issues that they were encountering in their lives since the birth. It was a healing experience. I think that the relationship between the mother and the baby reaches a crucial point at implantation. It is a two way biological affair. The mother accepts and the embryo commits to the pregnancy. This connection matures at birth and the casting off of the placenta after the baby is born completes this cycle. I’ve had a bit to do with so called retained placentas. There is usually unfinished business that needs addressing and it requires time and space for the process to complete. One case that comes to mind is a birth I was called to 5hrs after the baby was born and the placenta was still inside. The baby was still intact, that is the cord had not been cut. I spoke quietly to the mother and asked her what she was thinking about. She said that she kept thinking about Siamese twins. So I had her talk about the dynamics that might be involved in being a Siamese twin. We had a chat about the pros and cons of such a situation. The two-ing and fro-ing, the give and the take etc. In about 10 minutes and the placenta slid out effortlessly. There was obviously something in the unconscious that was needing to be addressed and using that wonderful metaphor the clever mother resolved the dilemma and could move on. A mother might prolong her birth time if she is not quite ready to let go of being pregnant or if the baby is unexpected and very close to another baby. These dynamics affect her bio chemistry and I always suppose that she is being wise and so long as the healthy signs mentioned in this post are present there is no need to rush. A friend who was a very experienced traditional midwife told me about a client of hers who held on to the placenta till the next day and it fell out as she stood at the kitchen sink. I think that our thinking as with many other thoughts we have about birth are seeded from the institutionalization of the process and procedures designed to serve the timetables of the institutions have become thought of as ‘normal’ Of course remembering that it is the baby’s organ is useful. I think that our own placental trauma plays a big part in how people behave during third stage. Many want to get their hands on it. Around the nation there are countless retained placentas in people’s freezers !The 2nd edition of Lotus Birth is at the printers I’m very happy to say, and will be available in the coming weeks.

  12. Love your description Gloria! Too bad there is so much medeling and routine pitocin. This seems to send the message that the body doesn’t know what its doing, you can’t depend on it. Then the inevitable tail of a mother’s power usurped.

  13. Dr. John was not the least bit concerned about placentas hanging on…he had one at 24 hours, too. His admonition to me on the topic was that it is a chemical sheering so we have to look at it from a chemical point of view, not a mechanical one….as in pulling on the cord will hinder not help…… I also agree that we don’t know how much we don’t know….. I always have taught that labor is the last dance…… but you know I have been completely wrong….the release of the placenta is really the “end” of that dance, not the emergence of the baby…. ….we outsiders would be wise to mind our own business….if there is not heavy bleeding going on, why do we care when the “end” is anyway?….it is still a private and oh so personal conversation between mamma and baby, yes? thanks Glo for always standing up for truth….

    • There is a balance to be drawn and that is the “art”. After 30 mins with the mother undisturbed and skin to skin with her baby, lights low, kept warm, given a warm drink (you DO have to be smart about what Mother Nature intends for birth), . . . I think about our great, great, great, great etc foremothers in a cave for my ideas about healthy postpartum. Warm, dark, secure, in the moment with her little naked baby, like a cat. If you have cell phones ringing, texting, flash bulbs going off, etc., not so likely that the placenta will go smoothly. If the people around are nervous, fidgety and need attention, that might change things. THINK AHEAD to foster a smooth placenta environment. There’s no advantage to leaving the placenta in over an hour. The mother gets a huge satisfied feeling of
      “I’m done, it’s complete” when it’s out. So, I strike a balance. I don’t worry about the placenta if the mother is alert, interested in her baby and looks lovely (postbirth glow). If she’s asking someone to take the baby and looks concerned, that’s a big red flag (very rare with an undisturbed bonding time) that something may be wrong. I think if homebirth mothers know this “thought train”, many of them will get more confident about the fact that the 3rd stage is just a continuation of the rest of the birth. They might also become more proactive about working with their mws to have a safe, smooth 3rd stage.

  14. Gloria,
    So you don’t do fundal massage then? What if you get a floppy uterus? Do you worry at all about tone, or will it all resolve itself? Women are made to feel like they will die and it will be their own fault if they don’t keep it up. Is that also false?

    • Devorah, I am talking about unmedicated women with continuous skin contact with their infants. I don’t do fundal massage—the baby would be disturbed if I did. There is no evidence to support all that fundus fiddling. Women tell me that the “expressing clots” assault by aggressive attendants is the worst thing they’ve ever experienced. No other mammal species does this. We could learn a lot from veterinarians.

  15. Wow! What a fabulous blog post.

    I have had a variety of personal experiences with 4 babies born vaginally and 5 second trimester miscarriages. The only time I did not have placental ‘issues’ was when we had a lovely, peaceful homebirth with an amazing, intuitive midwife. She gave me the impression that she was more interested in watching me bond with my newborn than what was happening with my placenta.

    It was not until more than an hour had elapsed that she began to wonder if there might be complicating factors with my obstetrical history. She began listing options including feeding baby and perhaps contemplating an injection of pitocin. I would have to find my notes to be sure but it was well over 90 minutes before I began feeling crampy again and the placenta was delivered in one push.

    I felt almost as proud of that accomplishment as our natural homebirth. I hated the interference after my other births and miscarriages. I am convinced that the D&Cs I have been subjected to could have been avoided if hospitals had more time and patience. I don’t imagine that is likely when time is money and medication is readily available. =)

    Thanks again Gloria for your amazing contributions!

  16. Have you ever experienced a placenta that separated, but then became hung up on the cervix, with a large clot forming behind it? I’ve just had two women in a row with that. We saw a separation gush, she had cramping, but in spite of woman’s efforts to birth the placenta nothing happened. After waiting around 45 min – 1 hr we followed the cord up and the placenta was right there (shultz), with a little traction and pushing from woman, it was birthed, but then a good sized clot and pooled blood followed. The clot alone was easily about 400cc. I want to wait for the placenta, but having two of these in a row makes me wonder if I had done a little cord traction at the first gush, would I prevented the extra bleeding? I’d love your opinion! =) thanks gloria!

  17. i was duped, read – poked with pitocin, placenta pulled out immediately and then fundal rubbed. it hurt and i still feel robbed. about to have my second baby and deeply excited to birth a placenta naturally for the first time. thank you for this post!

  18. I was a lucky one to give birth in a hospital, and have a natural third stage with the placenta coming out 45 minutes later! I was just too exhausted to even try to squat or assume any other position than lying, my baby was brestfeeding and so on… The doctor was a bit unsettled, coming in and out of the room, but the midwife was fantastic and I didn’t feel any pressure at all, even though she was encouraging me to try to birth the placenta.

  19. This post is one of the many reasons I keep reading what you write, Gloria. It’s so refreshing to have an experienced birth attendant truly focused on the mother and child, as they should be. You avoid ‘dissecting’ the birth into all of these parts and body parts, which is so great!
    Personally, my first birth was a ‘natural hospital birth’ (no such thing, really) where I was in ‘follow the directions’ mode and delivered the placenta as instructed, about 10 mins after the birth of my newborn.
    Second unassisted home water birth, the placenta came flying out as I moved from the tub to the couch, mid-stride and my friend magically caught it in a bowl. ;)
    Third birth, I hemorrhaged a bit after the birth, and just like you said, I knew I was not ok, and had a panicked expression on my face and handed our baby to his father immediately after the placenta came out in order to get out of the tub asap.

  20. This is such a great blog post! In my first unmedicated birth (3rd baby) I remember about 10 minutes after the birth vividly sitting in the tub and (after NO poking, prodding, massage, or anything) saying “um, can I push this thing out now?!” I could feel it right there and ready to come out, it was so easy! My CNM was pretty much hands-off and wonderful. I did the same with my 4th birth (both waterbirths). My sister, however, doesn’t birth her placenta until hours after the baby :( She has always had a VERY managed 3rd stage, pit, pulling, etc. I will always wonder if they had left her alone if it would have eventually come on it’s own.

  21. I just wanted to add my experiences to this… :)

    I have freebirthed all of my children, so in each circumstance, I was the one to worry about my placenta coming out. After I had my twins (first birth, 4 hour labor), the placenta came within a few minutes, and with no warning. We barely caught it in a bowl.

    With my third baby, I was in active labor for a little over an hour. Baby had a 1x nuchal cord, which was easily unwrapped after her head emerged. After she was born, I had little bleeding, which eventually stopped (to my husband’s amusement, I was moving about with a cord hanging out of me). An hour after the baby was born, we cut the cord, which still had a blue vein running through it. We had to clamp my end – even after an hour!

    I continued to experience regular, strong contractions, and nursed the baby at least 3-4 times before the placenta came. I felt fine (aside from the crappy contractions), had no bleeding, and after a few hours, it was still firmly attached and still needed to stay tied off.

    Finally, approximately FIVE hours after the birth, the placenta came like normal, and was whole. I had much less bleeding with that birth experience than I did with my twins, and also less postpartum bleeding (though it did last a bit longer).

    Who knows what would have happened had I not birthed unassisted…do midwives that are that patient even exist?

  22. Pingback: Don’t pull that placenta! « Lotus Midwifery • Rowen Holland, LM, CPM

  23. My experience of attending women giving birth at home is that for a physiological third stage it really is best to just wait and see….I work in the National Health Service as Home Birth Lead for our hospital and our hospital’s guideline is that we should intervene if the placenta is not expelled within an hour of the birth, but at home watching and waiting seems to work best. I have waited several hours but most placentae seem to come within the hour. I would never try and expedite this stage except in the event of a hemorrhage when the placenta needs to be out of the uterus to allow the muscle matrix to ligate the blood vessels in the uterus. In those circumstances, I would have first used a utero tonic drug such as syntometrine. I do think that women are less likely to hemorrhage though if the third stage is physiological and we respect the body’s ability to continue to process this by keeping calm and quiet and not getting in the way of the mum and baby’s extra uterine bonding.

  24. Pingback: Birthing the Placenta in the early days of Canada | Gloria Lemay

  25. My heartfelt thanks to Gloria for being the ONLY one to stand by me when I had 2 births with 60+ minute placenta deliveries.

    My Nelson, BC “midwives” abandoned me at week 38 when I told them of my relaxed method of completing my birth process.

    Love you always Gloria : )

  26. This blog post really speaks to me.

    Our 4th child was a peaceful drug and intervention free hospital birth until it was time for the placenta to be birthed. I had requested a natural 3rd stage, however the hospital had not heard nor had any idea of what or why it was requested and cut the cord at birth. From there they did the usual things, jab of sintocin, cord traction, timing the birth of the placenta, and tore my placenta. I then had the male midwife pummeling my tummy claiming he needed to get the placenta and any clots out asap (I mention that he was male as he was telling me that it can’t possibly hurt more than labour and telling me to hush and stop being hysterical, also he was very rough and hard with the massage!!! VERY hard!!!!) . It was like I was being cut open with no anaesthetic, like I was being stabbed every time he touched me and dug deeper. To read that others had a similar experience and saying the “massage” etc that they experienced was worse than the birth makes me feel kinda acknowledged. I know that I screamed and shouted “no. no” over and over but he kept doing the “massage”, telling me to be quiet and continued this for over an hour after the birth claiming it had to be done.

    I always wondered if I was being soft or sensitive to be feeling the pain and separation from my baby with this (he was with my husband as I was in so much pain and screaming I couldn’t hold him). Now I can close the chapter to this birth in a way knowing that what happened was NOT normal or right and it was painful. I wasn’t being soft or oversensitive.. I was being a normal mum who was for all intents and purposes being abused/assaulted and separated from my baby post birth due to faulty western medicine concepts. Thank you!!!

    • Reading this has made me feel a little calmer about my birth. Only by knowing that I was not the only one who was robbed of a peaceful third stage! I couldn’t hold my baby either and was also told to sit still and be quiet! Hopefully our next births are better x

  27. Gloria:
    I noticed the tea recipe for cramping with cinnamon and cramp bark, is this the same herbal tea used during the third stage?
    Thanks,
    Jennifer Warner
    Student Midwife in Texas

  28. Pingback: Standard Newborn Procedures and Maternal Procedures Immediately After Birth — Birth Takes a Village

  29. I had a home birth with our fourth baby, my second VBAC2. He was a much bigger baby than my other three (2.5 pounds bigger), but the labour and delivery were straight-forward except I was too much of a rush to push him out so I tore.

    Then the placenta didn’t come, and it didn’t come and the midwife couldn’t find the right suture material to stitch up my tear so we called our doctor friend to do the stitching which only made the placenta-worry larger. I had doulas asking me about my underlying ‘issues’, was I hanging on to the placenta b/c I knew it would be my last baby, yada, yada, yada. Finally my two closest friends and the doctor sat me down (I was wandering around with a cold wet cord slapping against my legs LOL!) and explained if I could please just focus for a few minutes and push it out I would avoid a trip to the hospital where my nemesis the Ob/Gyn would make me very miserable.
    This smartened me right up and I squatted, pushed and out it came.

    The next morning when I was rushing around cleaning up so my parents could visit our new baby and not freak out over the home birth I thought I smelled liver. Well! There was the placenta resting quietly in a metal bowl on a table in the upstairs landing. I whisked it out of the way in a hurry I can tell you.

    It would have been interesting to have taken the ‘no rush’ approach with my (our!) placenta to see if that would have taken the pressure off and allowed me to release it sooner.

    My daughter-in-law is expecting yet another baby in May and she is hoping that finally she can have a water birth. I have to trust the timing is such I can make it from terrace to Prince George to attend them. It’s only 567 km and she goes real fast!

    Bless you Gloria for all you do.

  30. this comment came in to my old blog: Author : Jacqui

    Comment:
    Reading this post and the comments makes me want to scream, YES! THANK YOU! I’m pregnant with my fourth, and it (hopefully) will be my second homebirth. My third was early and kind of a write-off as far as “patterns” go, but I’m getting flack from my midwife because I want a homebirth but had PPH after the first and second. Hence me finding myself here–the comment of “we’ll have to discuss this at our next appointment” has put me into high research gear. Only five weeks to educate myself so we can have a reasonable discussion!

    But the reason I want to scream is because everything I read echoes what shouldn’t have to be said: the most important thing is the mother’s own experience, and the effects of interventions are real and not my body’s fault! I didn’t have “interventions” at all during either of those labours and births, but afterward? YES. Absolutely. Painful kneading on my stomach by the OB after #1 to remove clots…am I naïve to believe that this ought to be looked at as a potential cause for my bleeding? Having to remove myself from the warm pool water and squeeze my placenta out squatting over a bucket in full light (felt like I was in a hospital anyway, even though it was my own kitchen), then walk across the house to my bed? Is it really that unreasonable to assume these factors related to the hemorrhage? And most importantly: should the hemorrhages even be counted, considering both times the only reason I even KNEW I was hemorrhaging is because I was told by someone else? I didn’t notice, I didn’t feel different, they did stuff to fix it and I was hardly aware. Why does this not count more than their estimated numbers? Hopefully it will…I haven’t had “the chat” yet. Just preparing for it; frustrated that my desire for home birth might be complicated again, just like with the third. A system that has developed to react to all the unnatural interventions it’s introduced has become discriminatory to the natural birthing mother–I feel betrayed. And irritated. Mostly irritated. But thank you for this added perspective and experiences. I don’t want to make an emotional choice, I want to make a good and reasonable one. I am increasingly convinced that in my case “hospital” is not that. Hopefully this information will help my midwife to agree!

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