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The Third Stage of Labor: Active Versus Expectant Management



The third stage of labor is the time period between the birth of baby and the delivery of the placenta. Commonly, hospital providers employ active management of third stage to mitigate the risk of postpartum hemorrhage (PPH). This involves early clamping/cutting of the umbilical cord, prophylactic administration of uterotonic medication (Pitocin is the first-choice, but Cytotec is also frequently administered), and controlled cord traction with suprapubic counter pressure. Conversely, expectant management involves supporting the release of the mother’s naturally-occurring oxytocin, waiting for the umbilical cord to stop pulsing and/or become white and limp, and incorporating gravity and mother-led pushing to bring forth the placenta. A few studies have show that active management significantly reduces the incidence of PPH, but when all things are considered, the risk versus benefit of implementing this approach across the board becomes more questionable.


What is PPH?


The American College of Obstetricians and Gynecologists defines early postpartum hemorrhage as “at least 1,000 mL total blood loss or loss of blood coinciding with signs and symptoms of hypovolemia within 24 hours after delivery of the fetus or intrapartum loss.“ It is estimated that between 3% and 5% of women will experience postpartum hemorrhage, so it is important to look at some of the conditions and practices that can contribute to its occurrence. Below is a list compiled by The Cochrane Database of some of the factors contributing to PPH:


Antepartum hemorrhage

Augmented labor

Chorioamnionitis

Fetal macrosomia

Maternal anemia

Maternal obesity

Multifetal gestation

Preeclampsia

Primiparity

Prolonged labor



How Effective is Active Management?


According to a clinical trial published in The US National Library of Medicine, active third stage management “significantly reduced” the occurrence of PPH >500 mL from 15% to 5%. It also reduced the risk of postpartum anemia and the need for blood transfusion. However, according to Evidence Based Birth, there isn’t any high quality evidence to show that it reduces the occurrence of PPH in excess of 1000 mL. Active third stage management was also associated with an increase in afterpains and the need for analgesia, as well as an increase in readmission for excess bleeding. It is also important to note that this clinical trial size was quite small at only 500 participants.


But, the bottom line is that incidence of PPH was decreased, wasn’t it? In this trial, it was. But if we look at the things that contribute to PPH, we should take pause because one very common hospital practice can lead to postpartum hemorrhage: induction or augmentation of labor. It’s difficult to find exact percentages of labors that are either induced or augmented. Most sources state that 1 in 4 women, or 25%, are induced and some sources place labor augmentation at or above 50%. So if hospitals create a situation that is more likely to lead to PPH, thus also increasing the incidence of PPH, then their postpartum interventions to stop it from happening are essentially reducing a number that they themselves inflated.


And here’s the real question: did active management interventions reduce the incidence of PPH to a level lower than what they would be in an entirely undisturbed birth? What would that study reveal?


What About Expectant Management?



This same Library of Medicine study notes that, in both nulliparous and multiparous mothers, third stage is typically complete within 30 minutes. Like all aspects of physiologic, undisturbed birth, it seems reasonable to assume this short delay serves a purpose. What is happening between the baby’s birth and the time the placenta is delivered?


  • Baby remains attached to its mother’s oxygen-rich blood supply through the patent umbilical vessels.

  • The ductus arteriosis and foremen ovale close within baby’s first few breaths, allowing baby to breathe on its own.

  • Baby’s blood glucose and body temperature regulate through skin-to-skin contact with its mother and initiation of feeding.


If this scenario sounds suspiciously like The Golden Hour, that’s because it is essentially just that. It is not a mistake but rather a physiological protective mechanism that keeps the placenta intact and providing oxygen and nutrients to the baby as it transitions earth-side. This attachment gives the mother time to assess her newborn, feed it, warm it, and begin bonding with it. It isn’t strange to want to allow this process to occur naturally - it’s instinct. In the absence of an emergency, our ancestral mothers had little choice but to tend to their babies’ immediate needs - they were quite literally tethered to them. And it makes perfect sense that the placenta that nourished and protected the baby for around 40 full weeks would continue to do so after birth until that baby is stable.


If we intervene less at the beginning, we won’t need to intervene more at the end.

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