From the Editor: Thoughts on Third Stage

Midwifery Today, Issue 146, Summer 2023.
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I have only had to do an internal bimanual compression one time. She was a redhead (although I do not believe redheads hemorrhage more). My partner, Monika, and I were at the birth, which progressed normally but was followed by a dreadful postpartum hemorrhage that followed the placenta. There was so much blood that I performed internal bimanual compression as Monika drew up Pitocin and gave her an injection. We were able to stop the bleeding with this serious method, but if I tried to let go before the Pitocin took effect, she kept bleeding. It took about eight minutes and worked great. Thank you, Marion, for your lesson on how and when to do this!

At that time in our practice, we did not know about using placenta, cord, or membranes for hemorrhage control, but I wonder if they would have stopped this fountain of blood or if bimanual compression would have proved necessary anyway.

I strongly believe that knowledge of using placenta, cord, or membranes this way can save lives. We have asked midwives in conferences and on Facebook about their experiences and found that, in most cases, it stopped the bleeding immediately. Considering that hemorrhage is still the leading cause of maternal death around the world, I think that knowledge of this method, if known by every midwife around the world, could save many lives. Just think of all the lives we could save with this little bit of ancient wisdom.

I liked this story by Gail Hart from a Facebook post: “I was helping at a birth recently. The placenta came quickly but the mother had a boggy uterus—one that relaxes and gushes a little so you have to keep a hand nearby to make sure it is contracted. It didn’t want to stay firm even with the baby nursing like a champion. So, as an experiment, we asked mom to try the cord. Mom took a piece about two inches long (three fingerbreadths) and put it in her mouth between teeth and gums. I had my hand on her uterus the whole time. Within one minute the uterus became firm and hard and the bleeding stopped. The uterus stayed hard from then on. Mom took the cord out of her mouth after a few minutes.”

Gail also taught me about using the membranes, which are always available once the baby is born even if the placenta has not been born. She noted membranes and the cord have even more hormones to fight hemorrhage than the placenta.

If in some parts of the world women have an aversion to placenta, membranes, and cord by mouth, they can alternatively be administered rectally. Again, we are talking about saving lives. These measures are not needed routinely because, thankfully, most women do not hemorrhage—especially if they are skin to skin with the baby and not disturbed. Michel Odent’s advice to not disturb the mother is important for bonding but also for hemorrhage control.

—Jan Tritten

Placenta is a source of prostaglandins. The amniotic fluid does contain some and it probably has a beneficial effect on mammals who instinctively lick their babies.

Like all older midwives (and doctors) we were taught that placenta could treat atony and hemorrhage, and I have successfully used it many times, but it was sure frustrating to have to wait for the placenta.

Many years back I found a bioassay of human placenta, which showed the cotyledons (the meaty part) contains prostaglandins, prolactin, and oxytocin, but that the cord and membranes have a much larger concentration of these substances. I was reminded that historical records show that First Nation’s women chewed the cord to stop bleeding.

We have the animal model where all mammals lick their newborns, mouth the amniotic membranes, and chew the cords; almost all of them consume their placentas. Hemorrhage is very rare in mammals other than humans.

These three facts were explosive—everything changes if we can use the membranes and cord to prevent or treat hemorrhage!

Not every birthing woman on the planet has access to medical care or a blood bank if she has trouble in third stage. But every single one of them has her own placenta, membranes, or cord available if she needs them.

—Gail Hart

Third stage demands patience and finesse to avoid potential problems. In hospital, it is more managed than in a homebirth. With that said, I have observed that once the placenta has truly separated, expediting delivery does seem to decrease bleeding. We instigate nursing right away and encourage the mother to relax back while holding her baby skin-to-skin. Often, if there is a tear, the MD or midwife will do the repair while waiting for the placenta, buying time for it to separate.

In the event that third stage is delayed, the practitioner becomes more aggressive. This happens at the 30 minute mark if there is no separation. I have seen the cord pulled, or a hand inserted and followed up the cord to see if the placenta is detached and just sitting in the lower segment. If a manual removal is needed, meds are given to help with pain and/or the woman who has had an epidural will still be numb.

I have been working in a hospital almost as long as I did homebirths. In my opinion there are pros and cons regarding how third stage is handled in both places. I tend to trust third stage until there is an indication not to, such as bleeding, pain, or long delay. My standard at home was based individually. I could afford a flexible standard of practice. Hospital birth does not allow for this, sometimes leaving me feeling like standards can be in conflict with care.

With the advent of Covid-19, third stage has been more challenging. We have noticed that women who have had Covid, more times than not, have calcified placentas, friable placenta tissue, and weaker cords. I am uncertain if this is because the placenta is taking the brunt of the disease or if the disease is causing the placenta to deteriorate. Regardless of which, it has changed the third stage of labor. We have seen more retained placentas, earlier delivery before term, more bleeding from partial separation, and more friable cords.

Fortunately, we have not seen much effect on the baby. This means that the incredible placenta is doing its job of feeding and protecting the baby. More studies will need to be done to ascertain the effects of Covid on pregnancy and birth. In the meantime we need to stay vigilant to mothers who have Covid and any effects on both mother and baby

—Jill Cohen

About Author: Jan Tritten

Jan Tritten is the founder, editor, and mother of Midwifery Today magazine and conferences. Her love for and study of midwifery sprang from the beautiful homebirth of her second daughter—after a disappointing, medicalized first birth in the hospital. After giving birth at home, she kept studying birth books because, “she thought there was something more here.” She became a homebirth midwife in 1977 and continued helping moms who wanted a better birth experience. Jan started Midwifery Today in 1986 to spread the good word about midwifery care, using her experience to guide editorial and conferences. Her mission is to make loving midwifery care the norm for birthing women and their babies in the United States and around the world. Meet Jan at our conferences around the world!

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About Author: Gail Hart

Gail Hart graduated from a midwifery training program as a Certified Practical Midwife in 1977. She has held a variety of certifications over the years; she was a Certified Midwife through the Oregon Midwifery Council, and an LDEM in the state of Oregon. She is now semi-retired and no longer maintains her license, but keeps active with a small community practice. Gail is strongly interested in ways to holistically incorporate evidence-based medical knowledge with traditional midwifery understanding.

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About Author: Jill Cohen

Jill Cohen lives in Mill City, Oregon, with two of her four children. After 20 years as a lay midwife she returned to school to become an RN. She is currently working in a small rural hospital as a primary OB nurse. She was the associate editor of Midwifery Today magazine from 1990 to 2007. View all posts by , and

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