#skin to skin
Pov daddy wants you to come by
POV mommy or daddy says to wear the dress they brought you
POV mommy or daddy saw you in lingerie and wants to devour you
POV daddy please me
Baby let’s get out of town and fuck on the balcony
Could be us but your playing
POV mommy’s wants some sugar right there and then
POV daddy’s pounding you from behind
POV your needy for mommy
Pov from morning sex with mommy was so good it went on till the evening and repeat
POV back scratching while the sex is so good
POV taking a hot bath with wifey she can’t take her hands of you
POV mommy’s needy
POV slut slumber party
POV your needy for mommy
s e n s u a l.
•Desire•
Picture from Earthside Birth Photography
Third stage of labour is simply the time from the birth of the baby to the separation and expulsion of the placenta and membranes. Sounds easy right?
During the third stage, the placenta detaches itself from the uterine wall and the muscles of the uterus contract tightly around the tiny blood vessels that have supplied the placenta throughout your pregnancy to prevent excessive blood loss. These complex hormonal and physical changes are all happening while you are meeting your new baby for the first time.
So What is all the Fuss About?
In developed countries, including Australia, Post Partum Haemorrhage is one of the leading causes of maternal death and morbidity (World Health Organisation). The most risky time for a woman during childbirth is during or immediately following third stage. In fact, you can loose a considerable amount of blood within the first 24 hours (primary haemorrhage) or even 24 hours to 6 weeks post partum (secondary haemorrhage).
Anything that may prevent the uterus from being able to contract down tightly around the many tiny blood vessels that were attached to the placenta, such as small pieces of placenta or membranes left behind that may have come away, a full bladder, a tired uterus or a uterus that has given birth multiple times previously and has lost its elasticity, will allow the blood vessels to remain open, exposed and continue to bleed. A similar concept to putting pressure on a cut or wound to stop the bleeding.
There will always be blood loss during the third stage and every women will be effected differently depending on her general state of health, level of haemoglobin at birth and function of the coagulation system. One woman may loose 1000ml of blood and not be compromised in any way and another woman may loose 500ml and become very unwell.
Lets Look at the Physiology
Taken from Physiology in Childbearing Third Edition by Dot Stables & Jean Rankin andMidwife Thinking
Separation of the placenta begins with the contraction that births the baby. The surface area of the placental site is rapidly reduced by the sudden emptying of the uterus to an area approx 10cm in diameter. This reduction results in compression and shearing of the placenta from the uterine wall. The contraction pattern is interupted as the placenta transfers its blood volume to the baby and hands over the job of oxygenation to the baby’s lungs. The placenta becomes less bulky and mother-baby interactions such as smell, touch (skin to skin), taste and sound stimulate further Oxytocin release and the uterus to contract. This is one of the reasons why skin to skin contact is so important following the birth.
As the placenta continues to be compressed by the contracting uterus, the blood in the spaces between your blood system and your baby’s blood system (placenta) is forced back into the spongy layer of the uterine lining (decidua). Retraction of the uterine muscle fibres constrict the blood vessels supplying the placenta, preventing blood from draining back through your blood vessels (maternal vascular tree). This causes congestion resulting in the veins rupturing and villi of the placenta shearing off the uterine wall. A clot then forms (retroplacental clot) behind the placenta and the placenta peels away.
Once separation is complete, the uterus contracts strongly and the placenta and membranes fall into the lower segment of your uterus and then into your vagina. You may get the sensation to “push” again but this time there is no bones!
So Where Does all the Blood Come From?
There is between 450ml - 700ml per minute of blood flowing to your uterus. This flow must be stopped in seconds to prevent serious haemorrhage. There are three factors involved in this process:
Living Ligatures: The tortuous uterine blood vessels are surrounded by the oblique muscle fibres, which retract and act as ‘living ligatures’ and constrict all of the blood vessels.
Pressure: Once the placenta has left the upper segment of your uterus, a vigorous contraction brings the wall of the uterus in opposition, applying pressure to the placental site.
Blood Clotting: There is an increase in the activity of your coagulation system during and immediately after placental separation so that clot formation in the torn blood vessels is maximised.
You can now see that anything that interferes or delays with the above processes, such as those discussed earlier, will increase the risk of more blood loss.
So How Long Does Third Stage Take?
When nature is left alone (physiological), third stage is usually completed within the hour but can take a lot longer. If you are giving birth in a hospital, there will be policies and guidelines that put a time limit on the process, for e.g. if you are choosing a physiological third stage and there is no sign of a placenta after 30 mins, the Dr will be notified and the Midwife will probably start preparing you for the administration of a prophylactic oxytocic drug (Syntocinon) to accelerate the process. If your blood loss is not substantial then you may be able to negotiate more time. Remember your consent has to be given to administer any drug and it’s all about being informed and educated. You will most likely be asked to sign a consent form at one of your antenatal visits for the administration of Syntocinon. If you choose a Managed third stage (see below for more information) your placenta is often birthed within 5 minutes.
What is the Difference Between Physiological and a Managed (Active) Third Stage?
A physiological third stage is where you allow nature to birth your placenta with no intervention. Once your baby is born the cord will be left to stop pulsating on its own and the placenta will be left untouched to fall into the vagina and birth spontaneously. The cord will then be clamped and cut. The cord may also be clamped and cut before the placenta births. This is something you can discuss with your Midwife.
A managed or active third stage is where as the baby’s shoulders are being born, or soon after, you will be given an injection of Syntocinon into your leg which causes the uterus to contract down hard and accelerate the processes discussed above. This lessens the amount of blood loss and is often the preferred choice by hospitals. The cord is clamped and cut and your Midwife will watch for signs of separation (cord lengthening, small gush of blood) and will apply pressure to your lower abdomen and gently “pull” on the cord (controlled cord traction) and lift your placenta out of your vagina.
How Do I Decide? Physiological or Active?
The physiological vs Active Management debate has been ongoing for years and I will explore this another time. There is alot of research out there now that discuss the benefits of physiological third stage for the baby.
As a new midwife still developing my knowledge, exploring the research and gaining experience, I feel its my role to provide the information individual to the woman and then support her choice.
If you have any risk factors that may increase the likelihood of increased blood loss such as a history of previous PPH (postpartum haemorrhage), a long or obstructed labour (tired uterus that may not contract around the blood vessels as well) or grandmultip (5+ births) then an active management maybe the better and safer option for you. If your labour and birth has had any type of intervention such as induction of labour, then the physiological processes have already been interfered with and it may also be a safer option to have an active third stage. During an induction the drug Syntocinon is used to bring on contractions. Syntocinon is a synthetic version of the hormone Oxytocin that your body produces to naturally bring on contractions, initiate milk production and as we have been discussing causes the uterus to contract down hard during third stage. Once Syntocinon has been introduced into your system it over rides your natural Oxytocin production and therefore if we were to remove it after the birth, the uterus would not respond as well.
If you experience a spontaneous labour with nil interventions then there is no reason why a physiological third stage can not be achieved. The idea is to promote effective endogenous oxytocin released by allowing undesturbed skin to skin, low lighting and quiet environment, no fiddling or touching of the fundus or cord and no stress or fear among anyone in the room.
Educate and inform yourself and talk about your individual experience with the Midwife or Doctor at your next antenatal appointment to make a decision that is right and safest for you and your baby.
Further Reading
Active vs Expectant Management for Women in Third Stage of Labor (A Review). (2011). Begley CM, Gyte GML, Devane D, McGuire W, Weeks A
Current Best Evidence: A Review of the Literature on Umbilical Cord Clamping (2001). Judith S Mercer
http://www.cordclamping.info/publications/LIT%20REVIEW%20ARTICLE-MERCER.pdf
