The 3rd stage of labor begins immediately after the delivery of the baby and ends after the expulsion of the placenta.The stage can be expectantly and actively manage.After delivery, it's followed by contraction and reduction in the size of the uterus, bloody show (sign of placental separation)and with contolled traction on the clamped cord it can be manually extracted.

We have 20 minutes for the III stage of labor in case of active or classical management.

In our hospitals 30 min for the third stage

Alright, same to my hospital..the third stage of labor is 30 min after delivery of the baby....

1 hour in the Netherlands.

Have you checked the NICE guidelines in the UK?

One hour in Italy

30 mins is allowed in most hospitals in nigeria

Our guidelines state that 30 minutes should be allowed in women undergoing active management of the 3rd stage and 60 minutes if physiological.

30 mins active 3rd stage management and 60 mins for physiological managment

If placenta is not delivered by 20 min, it wont deliver by 30 min. So one should start acting as soon as 20 minutes are over as to arrange for anaeshesia for manual removal it takes min 10-15 minutes. In this case also one has allowed 30 min for the placenta to deliver.

Also there are recent guidelines: Administration of oxytocin before or after placental expulsion does not significantly influence the major clinical outcomes such as the incidence of PPH or duration of the third stage of labour and increased rate of placental retention.

As a midwife, I wish to offer a more holistic perspective focusing on a physiological third stage in order to answer your question. Many of the interventions that occur in the normal physiological process of a woman birthing eg amniotomy, syntocinon infusion are to do with the imposition of 'time frames'. This subsequently impacts on how the third stage should be managed. Underpinning midwifery practice requires a respect for the physiology of placental separation and delivery. There is going to be a natural loss of blood when the placenta sheers from the uterine wall. This happens to all women and I have cared for many women who are surprised post caesarean section, that in their own words, ' I would bleed down below'.

For women who have not had an operative or instrumental delivery, as long as blood loss is not excessive and the mother is normally fit and healthy, and she has had a physiological labour preceding , she will be able to cope. It is important to bear in mind that the site of placental implantation also impacts on the speed of separation and how the placenta is expelled . As in waiting for a placenta, this fact only becomes apparent without the use of ultrasound at the very end (and so I also will return to it, at the end of my response).

Bearing all the above factors in mind the next step is to provide either a correct active management approach (no mix and match methods please) - which also opens up a whole new debate on the use of controlled cord traction or early cord clamping or a physiological third stage. But going back to your original question, I better focus on a physiological third stage approach ( no mix and match here either please) and it can sometimes takes longer than an hour. OK at this point, and this point only I will say some sort of intervention is required. But there is no point stressing out the mother, as long as there is no bleeding and her vital signs are within normal limits, it will be a case of not making a fuss about getting the placenta out, but getting the mother, to stand up to empty her bladder, and good old gravity, can do the trick. At this point , another thing can be tried which fits in nicely with another time imposition (and another debate - that babies should be fed within one hour of birth) if the baby has not fed, a breastfeed will be encouraged (physiology of lactation now plays a part). Before you go for a manual extraction, your hands can be put to good use by rubbing up contractions. Then if nothing happens an oxytocic can be given. The placenta should then be expelled shortly - is it by the Schultze method ( probably a fundal site implantation ) or the Mathew-Duncan method ( probably a lateral implantation)?

If this fails, then go for the manual extraction.

It depend on situation and all guidelines mentioned above are proving it.

I agree with Tina, there should be a holistic approach which focusses on whether the woman is well, can mobilise and labour has been physiological. Even with active mnagement of labour 30 minutes is not long!

Interestingly we found, for women with low risk pregnancies, that active management of labour increased their risk of PPH

Please see:

https://www.researchgate.net/publication/41942273_Holistic_physiological_care_compared_with_active_management_of_the_third_stage_of_labour_for_women_at_low_risk_of_postpartum_haemorrhage_a_cohort_study?ev=prf_pub

we have published a paper offering a theoretical perspective on this result. Please see:

https://www.researchgate.net/publication/24257000_Optimising_psychophysiology_in_third_stage_of_labour_theory_applied_to_practice?ev=prf_pub

There are more recent studies from NZ with the same result. I was talking recently to a midwife who has been working in a poorly resourced African country with women who would be considered high risk for postpartum haemorrhage and with the approach to third stage care as outlined above, they have helped 200+ women give birth with no PPH. I worked in PNG (in 2011) where there was often a lack of exogenous oxytocics - the midwives there knew to put the babies skin to skin with their mothers to reduce the rate of PPH. If you are interested in talking to the midwife who is working and teaching in Africa, please email me on Carolyn.Hastie AT scu.edu.au and I can put you in touch with her.

Article Holistic physiological care compared with active management ...

Article Optimising Psychophysiology in the third stage of labour: th...

From 30 to 60 min. If in normal labour

http://www.greenmedinfo.com/blog/how-eliminate-postpartum-hemorrhage

I have delivered 500 births without a single case of severe PPH using the above 3,4,5 protocol. I am looking for people to try it and document outcomes. [email protected]

Physicians tend to be the one's wishing for the rapid delivery so they can consider themselves done. I know some who give sublingual nitro if placental lasts more than 15 minutes post delivery. In many of our midwife deliveries the patient will be given up to an hour and then controlled cord traction and good old gravity will be attempted. The patient is monitored during this time and encouraged to breastfeed.

Hi Colleen, you get it. I think you are right about physician centred care (we want out of here) vs woman centred care; what is best for her and the baby.

Nirag, what makes you say that if a placenta hasn't delivered by 20 mins it won't deliver by 30 mins. We have plenty of examples using physiological 3rd stage care where it takes longer than 20 mins for the placenta to fall out.

Tina and those who agree with her speak in general terms without statistics, which makes it meaningless scientifically.

Scientifically speaking, waiting expectantly results in 1 in every 200 births having a severe hemorrhage of more than a liter.

There is a lot of scientific research behind this statement. Whereas, to date,

i have delivered 500 births, expediting the delivery of the placenta by getting the woman into squatting on the floor, feet flat on the floor at 4 minutes, without a single severe hemorrage. If others would only try it, they would likely agree that this is physiological third stage.

Do you pull on the cord?

slightly if needed.

Here is the protocol:

Judy’s 3, 4, 5 Protocol

At birth, immediate continuous skin-to-skin contact with the baby is initiated for the first 3½ minutes postpartum. If the woman requests cord cutting (after explaining that it makes it easier to deliver the placenta and that you will check that the cord is contracted and coagulated) cut it at 3 minutes. The midwife keeps her hands off the fundus. At 4 minutes the midwife directs the mother into a good deep squat with her bottom almost touching the floor and her feet flat on the floor or the floor of an empty bathtub. The first few times you try it, the midwife should use a low plastic bowl to measure blood loss. If the mother requests for the cord to be cut, the mother hands the baby to someone. If not the midwife or someone else holds the baby close to the mother or put the baby on the floor wrapped up. (obviously it is more convenient to cut the cord and the cord is already clotted and not working, so not sending anything to the baby) The midwife gives verbal encouragement to push. The woman will not feel a contraction – she pushes without feeling a contraction. If the placenta is not delivered by 5 minutes 0 seconds, the midwife helps the cord to come further out by gently pulling down about 15 cm of cord and reassures the mother and herself that the placenta is very low and all she has to do is push. The woman is in a low squat while she pushes out the placenta. The time of delivery is noted. Immediately after delivery of the placenta, the mother stands up, is helped to put on an absorbent pad (I use a baby diaper) (and underwear if she wants), helped into bed, and immediately given the baby. The uterus is then immediately massaged to check for clots. If blood completely fills the disposable diaper during the next five minutes, a shot of either 10 IU Pitocin IM or 0.2 mg methergine IM (intramuscularly), or both is given at 10 minutes postpartum. Suckling at the breast is initiated. If a woman has a history of PPH>1000 mL at a previous birth, or if she is had twins, prophylactic methergine 0.2 cc IM should be ready, but will rarely be needed after the placenta is delivered.

YouTube : http://www.youtube.com/watch?v=LOp6Z4mahvA I finally put it on YouTube, but in this case, the woman had a history of previous PPH > 1500. The placenta separated right after the baby came out, signaled by a shluck of blood, so I cut the cord at 2 minutes and delivered the placenta at 4 minutes. I dont have to cut the cord, but she requested it before the video starts. It gives you some idea of how it goes. It looks more interventive than usual, because usually there is an extra minute more time. But this is the first woman who agreed to be videoed. I hope to make more (but i have a very camera shy clientelle) She felt great after birth- hardly any blood loss. Very satisfied customer. Both her parents are Family Practitioners.

Hi Judy, I generally respect you but on the matter of how you 'manage' third stage I have to disagree. Your approach is very interventionist, you direct the woman what to do, you take the baby from her. I do not understand why you just do not support the woman's own reproductive physiology.

You are lying to yourself and to the readers of this site. You dont respect me or you would try it once. All you have to do is try it once to realize it is the most natural and most in tune with the womans reproductive physiology and allows the woman the most bonding time with the baby. Much more than your method. And best of all, prevents hemorrhage. Using your method, you get about 4% PPH and 0.5% severe PPH. So you not only do not respect me, you do not respect the womans right to a safe birth without hemorrhaging enough to try my protocol even once.

I have yet to meet a woman who says- "I prefer to hemorrhage rather than squat at 4 minutes, or hand the baby to my partner for 60 seconds ." If you could claim your protocol results in no severe hemorrhage, then you would be able to say you support a woman's natural physiology. There is no historical recording of a woman hemorrhaging before the year 1400. It is your protocol that has caused this to start as women lost the habit of squatting. Hemorrhaging at birth is not recorded in the entire talmud even though one of the six books is entirely devoted to uterine bleeding. It documents bloodless births, which sometimes do happen using my protocol.

When you say you honor a woman natural physiology, do you mean that you eliminate the use of insulated homes, electricity, flush toilets, pens, cell phones, heaters, machine washed blankets and freedom from predators? Do you throw all of those away to support the woman's own reproductive physiology? Of course not. You just throw away squatting before the cervix closes down. Because doing so works 96% of the time and because you have lost the habit of squatting because of toilets. And because you are closed minded to new (old) ideas.

But there is hope because you have been willing to have this conversation.

Judy, I find your response abusive and not conducive to dialogue.

Schultze method or the Mathew-Duncan method do not exist. These technique were described before 1900. Conventionally it could be 30 minutes. But it would be dangerous if mother is bleeding and you are waiting. it would be also dangerous if mother is not bleeding after one hour or more and you are introducing your hand within uterus. every case has to be individualized. USG can be done to know the thickness of placental implantation site and compaire with it to the rest of the myometrium. Color Doppler to the uterine artery. If resistance index is low try to detect placental accreta or trapped placenta. Physiologic management is better in case of healthy mother with good hematocrit. Before USG you can try to detect the placental separation by Brandt's and Andrew,s techniques. Two are different. Controlled cor trction can partially separate the placenta and may cause profuse third stage bleeding.

Are not over focusing on retained placenta? Strategies on how to improve universal access to UN Signal functions of BEmoC and CEmOC that can prevent 75% MMR to rural sub saharan african communities without basic social amenities are more burning issues. Skilled birth attendants ran away from such communities giving room for TBAs to practice without limitations and with a lot of associated deadly complications

Hi Okafor, I agree, skilled birth attendants are critically important. Most important, however, is the health of the woman before and during pregnancy, labour, birth and postpartum. No amount of medicine can substitute for good health.

The discussion of issues around the 3rd stage of labour should presume that we are able to differentiate individual needs, settings and environmental situations! To read studies critically requests also to read between the lines and to identify the intention of the autors. Doing so, we have to consider if - in industrialized and high income countries - highly interventive practices and medication are more risky than hands off! If there is a 0,001% risk of mortality due to PPH in high income countries (www.awmf.org/)‎ or a general risk of 5% (International Postpartum Hemorrhage Collaborative Group 2009) to suffer from severe ppH and active management is the official recommendation for every woman worldwide, then this means for my home country Austria (about 77.000 deliveries of fullterm singletons/year (Statistik Austria 2013) that because of 3.850 women who might suffer from any kind of ppH (I, II or III) respectively because of one woman in 18 month, who might die (we can´t predict a risk, only suppose) 77000 women are forced to accept a violent and painful intervention that is not intended by nature and interrupts the bonding - process dramatically.

There is no chance to find any studies about the incidence of ppH after "controled chord traction" (we all know about heavy bleedings after someone "helped a little bit - don´t we?), there is no severe analysis of the effects of syntcinon or methergine on the newborn or on breastfeeding efforts. Even if we know that high doses of syntocinon are a risk factor for atony because it weakens the myometrium and blocks oxytocin-receptors, we use it inflationary. I know that private experience has no scientific value, but it is - of course - evidence and thanks to my personal evidence of 10 years homebirth - experience I know that the placenta is a very intelligent organ, that supports the baby not only during pregnancy but also postpartum until it is well adapted. There is an old saying of our midwife-ancestors: " Never injure placenta and egg membranes, they are holy! "

The discussion of issues around the 3rd stage of labour should presume that we are able to differentiate individual needs, settings and environmental situations! To read studies critically requests also to read between the lines and to identify the intention of the autors. Doing so, we have to consider if - in industrialized and high income countries - highly interventive practices and medication are more risky than hands off! If there is a 0,001% risk of mortality due to ppH in high income countries (www.awmf.org/)‎ or a general risk of 5% (International Postpartum Hemorrhage Collaborative Group 2009) to suffer from ppH and active management is the official recommendation for every woman worldwide, then this means for my home country Austria (about 77.000 deliveries of fullterm singletons/year (Statistik Austria 2013) that because of 3.850 women who might suffer from any kind of ppH (I, II or III, included Ceserean sections with "physiological" bloodloss of about 1000ml) respectively because of one woman in 18 month, who might die (we can´t predict a risk, only suppose) 77000 women are forced to accept a violent and painful intervention that is not intended by nature and interrupts the bonding - process dramatically.

There is no chance to find any studies about the incidence of ppH after "controlled chord traction" (we all know about heavy bleedings after someone "helped a little bit - don´t we?), there is no severe analysis of the effects of syntcinon or methergine on the newborn or on breastfeeding efforts. Even if we know that high doses of syntocinon are a risk factor for atony because it weakens the myometrium and blocks oxytocin-receptors, we use it inflationary. I know that private experience has no scientific value, but it is - of course - evidence and thanks to my personal evidence of 10 years homebirth - experience I know that the placenta is a very intelligent organ, that supports the baby not only during pregnancy but also postpartum until it is well adapted. There is an old saying of our midwife-ancestors: " Never injure placenta and egg membranes, they are holy! "

The discussion of issues around the 3rd stage of labour should presume that we are able to differentiate individual needs, settings and environmental situations! To read studies critically requests also to read between the lines and to identify the intention of the autors. Doing so, we have to consider if - in industrialized and high income countries - highly interventive practices and medication are more risky than hands off! If there is a 0,001% risk of mortality due to ppH in high income countries (www.awmf.org/)‎ or a general risk of 5% (International Postpartum Hemorrhage Collaborative Group 2009) to suffer from ppH and active management is the official recommendation for every woman worldwide, then this means for my home country Austria (about 77.000 deliveries of fullterm singletons/year (Statistik Austria 2013) that because of 3.850 women who might suffer from any kind of ppH (I, II or III, included Ceserean sections with "physiological" bloodloss of about 1000ml) respectively because of one woman in 18 month, who might die (we can´t predict a risk, only suppose) 77000 women are forced to accept a violent and painful intervention that is not intended by nature and interrupts the bonding - process dramatically (both active management and unnecessary ceserean section - where are the lots of studies who point out the rate of not - emergency cesereans?) . There is no chance to find any studies about the incidence of ppH after "controlled chord traction" (we all know about heavy bleedings after someone "helped a little bit - don´t we?), there is no severe analysis of the effects of syntcinon or methergine on the newborn or on breastfeeding efforts. Even if we know that high doses of syntocinon are a risk factor for atony because it weakens the myometrium and blocks oxytocin-receptors, we use it inflationary. I know that private experience has no scientific value, but it is - of course - evidence and thanks to my personal evidence of 10 years homebirth - experience I know that the placenta is a very intelligent organ, that protects and supports the baby not only during pregnancy but also postpartum until it is well adapted. There is an old saying of our midwife-ancestors: " Never injure placenta and egg membranes, they are holy! "

I am interested in the 4 minutes squatting... what physiologically happens to have this make sense?

Do you think that emptying the bladder is important?

Don't instruct mothers to do it; let them be more spontaneous but upright. My understanding of reproductive physiology is that it functions best when the mammal (yes, women are mammals) are left undisturbed and merely observed for any signs of abnormality. Women and babies should be skin to skin and early baby-initatied breastfeeding will commence in a warm, calm, loving environment. For a well woman and baby this leads naturally to placental birth and a loving bond between mother and baby. We truly cannot improve on normal physiology and trying to do so creates not only PPH but also problems with breastfeeding and bonding. "She also serves who only stands and waits"

I agree with Tina too, and it depends on woman's situation and everything should be under control without any force.

I published my outcomes using my protocol and none of my births end in severe postpartum hemorrhage. Kathleen Fahy published her outcomes and 1 in every 200 of her births ends in a severe postpartum hemorrhage with the woman losing more than a 1000 cc of blood. Women strongly prefer not to have a severe postpartum hemorrhage. Since women have to deliver the placenta at some point, it is much better for them to do so sooner than later, in addition to not losing a liter of blood, it is also better because the husband and kids can enter and all the blood is gone- the mother has a pad, underwear and clothes on at 6 minutes and they can all bond without the interruption of delivering the placenta, which for 1 in 200 will involve a major postpartum hemorrhage, IV and perhaps transfer, and feeling weak for weeks afterwards.

According to her own statements, Kathleen Fahy has never tried my protocol once to see if it feels natural or unnatural. My protocol feels extremely natural. A person who refuses to try a new protocol once, which professes to totally prevent severe PPH, appears to have a lack of openness to scientific experimentation meant to advance the field of midwifery.

If the woman and birth were undisturbed, she would be alone in a forest with no electricity, heat or cell phone and certainly no IM Pitocin or methergine in the fridge. And she damn well would get rid of that bloody placenta before predators came to get it. Just put a placenta outside for a minute and see how fast the local cats and dogs come to eat it. So the argument that not squatting is "natural" is so ridiculous, it is amazing that anyone on a scientific website like ResearchGate is willing to take such a stance. Such people hold that everything is natural- IVs, medications, central heating, down blankets, refrigerators, ovens, telephones, indoor plumbing, disposable pads, but ask a woman to squat to prevent bleeding and that is supposedly unnatural. Ridiculous.

What is the physiology behind the protocol?

The placenta is detached by one minute postpartum because the uterus has completely changed shape without the baby inside. The uterus cannot contract enough to always prevent hemorrhage while the placenta is inside. Deliver the placenta, the uterus contracts and prevents hemorrhage.

Yes, having an empty bladder is always a plus- but most women who push the baby out, will also push urine out in the process. SO a full bladder is usually only a problem where the woman is anesthetized with an epidural or during vacuum or cesarean births.