Birthing The Placenta: Do I Have To Have The Injection?

The birth of a placenta is referred to as the third stage of labour. The first stage being the bulk of the labour itself, and the second being the pushing/birth stage.

Although the party isn’t over after your babe is born, fortunately the placenta doesn’t have bones, and it is relatively painless to birth. It is however a bit ‘weird’ feeling when it comes out, and you may experience some cramping.

Few women know there is actually options around how you birth your placenta. And I’m not talking about whether you’re going to plant it under a tree or consume it in tablet form… what to do with the placenta after birth has already been written about – I really should have written this one first.

So what we’re talking about here is “active management” versus “physiological management” of the birth of the placenta.

Very simply put, ‘active management’ means the mechanical removal of your placenta by your Midwife/Doctor with the use of a drug that is injected into your leg and traction on the cord. ‘Physiological management’ means the process of allowing the body to birth the placenta on its own without interfering, pulling, or injecting medication.

But don’t stop reading there… to make a fully informed choice, there is a lot more to learn.

Just as our body knew how to grow a baby without us telling it how, it knows how to birth a baby and placenta. This is why physiological management should be considered the standard or the ‘norm’, with active management being the variance. Just as vaginal birth is the norm and caesarean is an alternative when required.

Sadly, in a lot of hospitals it is the other way around and active management of the placenta is most common, so much so that some Midwives don’t know how to support a physiological third stage.

When you take into consideration increasing intervention rates, 92% of women not having continuity of carer, unfamiliar faces, bright and sterile hospital settings, separation from baby and the time constraints and distrust in physiology of birth, it perhaps explains why so many health care providers advocate for active management.

All of these factors negatively impact the hormones of birth like oxytocin.

Your body is not a dud. It knows how to birth a placenta. But if there are factors that hinder the hormones of labour, create stress, and increase adrenaline, your body can’t work as well is it could have. That then increases your risk of a postpartum haemorrhage (PPH) [a blood loss of 500mL+].

Why?

Because the placenta being birthed is dependant on the uterus, and the uterine functioning is dependant on hormones. Once your baby is born, the uterus continues to contract. This aids placental separation and birth, as well as preventing heavy blood loss.

Think of it as an open wound on your leg – what are you going to do to stop the bleeding? Put pressure on it. The same way, after birth, the uterus contracts down, clamping off the thousands of open vessels where the placenta separated from, and stops the bleeding.

It is normal to lose up to 500mL of blood at birth. Your body’s blood volume in pregnancy increases by 2 litres to cope with that. Anything larger is considered a PPH and could require interventions.

Active management is used to encourage the clamping down of the uterus and prevent PPH. There are some circumstances which may increase your risk of a heavy blood loss, and so active management will be recommended by your care provider –

• Induction of labour
• Very long labour or interventions in labour – the uterus is a muscle, it can become tired, mix that with a hit to the hormones of labour and it can struggle to contract down as needed.
• Shoulder dystocia
• Previous PPH
• Vacuum or forceps birth
• Clotting disorder
• “grand multi” – 5th or more baby
• and so on. Your health care provider should discuss this with you.

Some hospitals have a policy that all women have active management of the placenta. Policy is not law, meaning you can make an informed decision about how you will birth your placenta.

Though it is important to have a discussion with your health care provider surrounding your own individual risks, and be open to changing the method of third stage management in unforeseen circumstances.

Potential complications of third stage, though rare, include snapped cord and uterine inversion.

With the nature of active management being haste to pull the placenta out with cord traction following administration of a uterotonic drug – one would assume these complications may be more related to care provider actions during active management. While in physiological management, the care provider takes a hands off approach as described below.

Physiological management, the biological norm, is safest when a healthy woman’s hormones and birth have been undisturbed and uncomplicated.

It is crucial to ensure your care provider knows how to facilitate a physiological third stage. These are some strategies I use (considering labour and birth was physiological and undisturbed) –

• Keep the lights dim – fluorescent lights disturb physiology
• Keep mum feeling safe, private and unobserved ( I sit near Mum, observing closely, but not in a way she feels watched)
• Keep mum WARM
• Keep baby skin to skin with mum
• Suckling at breast and looking at baby can help the uterus contract
• Keep mum in an upright position so gravity can assist placenta out – toilet or birth stool are great
• Encourage mum to wee if she can
• Talk mum through any worries or fears she may be having
• Explain to mum what is normal to feel
• Encourage coughing – do it now and focus on what happens to your pelvis
• It is OK for the placenta to take up to an hour to come (vs half hour for active management), but more commonly we see them come within half hour of birth… because in undisturbed birth, the oxytocin is flowing!

Ultimately, there is no debate of whether active management or physiological management of third stage is better. Both have their place, both are important for their own reasons, and both should be considered placed against a woman’s individual health circumstances, history, and labour/birth needs.