Giving birth - third stage of labour

The third stage of labour starts after your baby is born. During this stage, your placenta naturally separates from the wall of your uterus. The placenta and membranes that supported your baby in your uterus during pregnancy are then passed out through your vagina.

This stage is not usually painful, but you may feel some discomfort. It is an important part of completing your birth process.

During the third stage of labour, the umbilical cord is also clamped and cut. This is not

painful for you or your baby. If you have arranged to bank or donate cord blood, you can discuss this with your midwife who can collect your baby's cord blood after the cord is cut.

Cord clamping usually happens after the cord has stopped pulsating (usually about a minute after your baby's birth). This allows your baby to receive more blood from the placenta, which may reduce the chance of iron deficiency later. Your midwife or doctor may need to cut the cord immediately if you or your baby is unwell at birth.

If you prefer to keep the cord connected for longer or if your birth partner wishes to cut the cord, let your midwife know in advance and include this in your birth preferences.

After your baby is born, your placenta naturally separates from the wall of your uterus. You may feel mild contractions as it comes away. Your midwife may ask you to push gently to help the placenta pass through your birth canal.

There are 2 ways your doctor or midwife can support this process — physiological (expectant or natural) management or active management.

Because the evidence comparing these approaches is limited, it's helpful to talk with your midwife or doctor during your pregnancy about your options. This can support you to make informed decisions before giving birth. Your midwife will keep checking on you and your baby and can also support you with breastfeeding during the third stage.

Physiological management

Physiological management (also called expectant or natural management) means that you pass the placenta without medical intervention with the help of your uterus' natural contractions. Your midwife mainly observes and waits for signs that the placenta has separated and if needed, gently guides it out while you push.

This is usually recommended for people with a healthy, low-risk pregnancy. It usually involves:

• no medicines (unless bleeding occurs)
• delaying cord clamping until the cord stops pulsating or the placenta is out
• no intervention

Active management

Active management involves medical support from your doctor or midwife such as:

• an oxytocin injection to help your uterus contract
• clamping of the cord
• controlled cord traction after signs of placental separation

Active management usually speeds up passing the placenta and reduces the chance of increased postpartum bleeding. It is more likely to be recommended if you have a higher risk of heavy postpartum bleeding such as:

• prolonged labour
• induction of labour
• previous postpartum haemorrhage
• anaemia

An actively managed third stage of labour usually takes anywhere up to 30 minutes. If you choose a physiological third stage, it can take up to an hour. Any longer than these times is considered prolonged. Your midwife and doctor will continue to assess you and discuss your options with you.

People and families have different cultural, spiritual and personal practices around the placenta. Your choices should be respected.

Here are some common options:

• Lotus birth — leaving the placenta attached to the baby until the cord naturally separates. This may take 2 to 5 days. If you prefer this practice, speak with your midwife or doctor in advance.
• Placenta burial or cultural ceremonies — some families choose to bury the placenta as part of cultural or personal tradition.
• Placenta encapsulation — the placenta is dehydrated and processed into capsules that you swallow. Evidence about benefits or risks is limited.
• Taking the placenta home — you may simply wish to keep the placenta for personal or cultural reasons.
• Hospital disposal — the hospital throws away your placenta.

The skin and tissues between your vagina and anus (perineum) can sometimes tear when it is stretched during birth.

After your placenta passes, your midwife will check your perineum for tears. They will assess how deep these are and where they are located.

Small, shallow tears may not need stitches, but larger tears may be stitched so they heal properly. This helps reduce your chance of complications.

If you need stitches for a tear or an episiotomy, your doctor or midwife will provide you with pain relief.

Your birth partner can usually stay with you throughout this stage of labour and provide you with support, for example, by reassuring you and bringing you anything you need.

If you prefer privacy at any time during labour, let your midwife know — it's always your choice.

Your baby is usually placed on your chest with consent after they are born, for skin-to-skin contact. You will both be covered with a blanket to stay warm.

This is also a good chance to breastfeed your baby for the first time, if you would like to. You may find that this is a great way to start to bond with your newborn, even if you plan to bottle feed later.

Breastfeeding during this time can:

• shorten the third stage of labour, as it releases oxytocin, which contracts your uterus and helps the placenta pass
• reduce the amount of bleeding you may have after birth
• keep your baby's blood sugar levels normal

Your midwife will offer to weigh your baby and give them medicines such as vitamin K (injection) with your consent, but there is no rush. If you are both well, this is a good time for you to meet and enjoy your baby.

There can be complications in the third stage of labour where extra medical support is needed. The main complications include:

• heavy bleeding (postpartum haemorrhage)
• the placenta not coming out on its own (retained placenta)
• the placenta growing too deeply into the uterus (placenta accreta)
• tears in the vaginal or perineal area
• the uterus turning inside out (uterine inversion) — this is very rare

The medicines used to treat complications may cause:

• a short-term spike in blood pressure (postnatal hypertension)
• nausea and vomiting
• stronger cramps
• increased need for pain relief

Your midwife or doctor will help you make the best decisions for you and your baby. Talk with them during your pregnancy about your preferences so you know your options and can make informed choices.

For more information or support, the following organisations and services can help:

• The Australian Government has a range of pregnancy information resources.
• The Royal Australian and New Zealand College of Obstetricians and Gynaecologists provides a pamphlet on labour and birth.

Languages other than English

• The Multicultural Centre for Women's Health offers a library of pregnancy, birth and postpartum resources in many languages.
• Monash Health has health information translated into many languages, including pregnancy care topics.

Information for Aboriginal and/or Torres Strait Islander peoples

• Birthing on Country supports culturally safe, community-led maternity care for First Nations families.
• Find an Aboriginal Community Controlled Health Organisation (ACCHO) near you.

Information for sexually and gender-diverse families

• Rainbow Health Australia has a library of practical resources on services for sexually and gender-diverse (LGBTIQ+) families.
• QLife is a free, national phone and webchat service that provides anonymous peer support and referrals for LGBTIQ+ people and their families.