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Positive Birth Stories for all Types of Birth

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Positive Birth Stories for all Types of Birth

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Positive Birth Stories From Our Community - Read Now

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The #1 resource for positive birth stories. Including home births, water births, inductions, planned and unplanned cesareans, first time to fourth time mums.

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Can I choose where to give birth?

Yes. You have the right to choose where you give birth. You can choose to give birth in a hospital, in a birth centre, or at home. A birth centre is a maternity unit that is run by midwives. It can be part of a hospital or completely separate.

Your NHS trust may automatically book you into a hospital or birth centre. You can ask to discuss this and make your own choice.

A healthcare professional may say you 'need' or 'have' to give birth in a hospital. You can ask them why they think this. What medical reasons do they have for this advice? You do not have to agree with them.

In some cases, there may be restrictions on your right to choose a hospital or birth centre. However, no-one can make you give birth away from home if you want to stay at home.

The only time someone else can decide for you about where you give birth, or your treatment, is if you lack mental capacity. This is very rare, but we describe what mental capacity is below.

Yes. You have a right to choose where you give birth. You cannot be made to go to hospital. Healthcare professionals may want to talk to you about your plans and any concerns they have. This should be an opportunity to have an open discussion and to share information. They should always respect your views and choices.

All NHS Trusts are expected to run a home birth service. This is not guaranteed in law, but the law says that your right to choose where to give birth should only be restricted when there is a good reason to do this, and where the decision is 'proportionate'.

This means that a Trust should only pause their home birth service if they have looked at all the options for keeping it going and they are still unable to.

If you are told you cannot give birth at home because of staff shortages, remind the hospital that it must make sure there are enough staff to provide the services it has promised. They should have plans for situations such as staff shortages. This could include providing an independent midwife.

If you feel that your choice to give birth at home is not being respected, you can contact Birthrights for advice using our contact form.

Yes. The Nursing and Midwifery Council's Code says that midwives must put your interests first and make your safety their main concern. This is their professional duty.

Midwives should respect your decision to give birth outside the hospital. They should attend you at home if you ask for this, even if they don't agree with your decision.

If you are in labour and the hospital tells you there is no midwife to attend you, (and that they will send an ambulance), you cannot be made to attend hospital if you do not want to. You or your birth partner can ask to speak to the Head of Midwifery and ask them to provide a midwife.

If a midwife - or any healthcare professional - has breached their duty of care, you can complain. Duty of care means that they must care for you and keep you safe. They can be referred to their regulatory body, which will investigate.

Yes. Only you have the right to decide where you give birth. No one can overturn the decision you have made. This is the law.

The only time that someone else can make decisions about your healthcare is if you lack mental capacity to make those decisions. This is very rare.

Even if healthcare professionals advise you not to give birth at home, no one can make you go to hospital.

Your midwife and hospital consultant (if you have one) should work with you to make a care plan for giving birth at home.

When professionals give you advice and information about where to give birth, it should be based on facts, not personal opinions.

Healthcare professionals must not put pressure on you, or threaten you, when you are deciding where to give birth. They must not threaten to involve social services. If you feel this has happened, you may not have given consent to the treatment you received. This could mean that the healthcare professional can be taken to court for failing to obtain your consent.

Yes. All people in the UK have a right to maternity care in hospital.

Your GP will tell you which hospitals have maternity services in your area, and you can choose which one to use.

You can ask to use a different hospital. If your GP will not refer you to the hospital you choose, you can refer yourself. Look on the hospital's website or ask its maternity team for the self-referral form.

Yes. The government says everyone in the UK should be able to choose between giving birth in hospital, in a birth centre, or at home. You should be offered a full discussion of the risks and benefits of the options you are considering.

If there is no birth centre in your area, or you want to use a different birth centre, you can ask your GP to refer you or you can refer yourself.

Birth centres often have rules, called admissions criteria, that say people with 'high risk' pregnancies cannot use the centre.

These are not legal rules and they cannot be applied in a blanket way. The centre should use them only to guide them when making a decision about who can use the centre.

The birth centre must only refuse to allow you to use the centre if they feel they cannot provide you with safe care. The centre must have a good evidence-based reason that shows you or your baby are at high risk of harm when giving birth without the support of a hospital obstetric ward. The centre must be able to show that it cannot safely manage that risk. They should consider the risk on a case-by-case basis, looking at what the risks are in your personal situation.
For example, a birth centre might say you cannot use the centre if your labour is being induced and where medical advice strongly recommends the monitoring of your contractions.
Or the birth centre's rules might say that you cannot use the centre if your body mass index (BMI) is above a certain level. However, they should look at what the specific risks are in your case and whether they can be safely managed. They need to have evidence for what they say. They need to discuss it with you, and if they think they cannot safely care for you in the birth centre they need to discuss what alternatives they can suggest (for example, offering similar support such as a birth pool on the labour ward).

Both hospitals and birth centres must make 'reasonable adjustments' so that anyone with a long-term health condition or disability has equal access to their services. This is law, under the Equality Act 2010.

These adjustments could be in the way the hospital or birth centre provides care, accessing and navigating the buildings, providing equipment, or providing services such as British Sign Language interpreters or extra support.

The Equality Act 2010 says the midwifery team should talk to you about what adjustments you need. Your midwife can also ask for help from other teams in the hospital, such as Occupational Therapy, if necessary.

They should talk to you from the start of your pregnancy so that together you can work out the best way they can support you throughout your pregnancy, in labour, and during your post-natal care.

Having a long-term health condition, disability or sensory impairment does not take away your right to choose where you give birth.
For example, a woman who uses a wheelchair should be given a room that she can access in her wheelchair as well as a bathroom that she can comfortably access. She should also be provided with appropriate aids such as a shower stool and toilet frame. An autistic person may ask for a familiarisation tour of the ward or have sensory considerations in their birth plan to make the environment accessible.
If you need help to communicate with healthcare professionals, ask as early in your pregnancy as possible so that you can make informed choices from the beginning.

This might be support with British Sign Language interpreters, large print materials or materials in a form that is suitable for your screen reader.

This might be access to an interpreter for your appointments and care.

Yes. A birth plan lets you tell healthcare professionals about the kind of treatment and care you want.

Your midwife or doctor should help you to make a birth plan (this may be called a personalised care and support plan) that will be included within your maternity records (your digital or handheld notes). If you choose care that is 'out of guidelines' then you may find it helpful to make your birth plan with a consultant midwife or doctor. Your plan should be recorded so that any doctors or midwives who care for you can find it. You might also want to print a copy so that you can give it to your doctor or midwife when you are in labour.

This can include where you want to give birth, so thinking about your birth plan will help you to explore the options and decisions you might make.

You may find it useful to think about what is important to you before you make your birth plan. This can help you to think of the questions you want to ask the healthcare professionals who are supporting you. It can help you have a clear and respectful discussion with them about where you want to give birth and what care you want during and after the birth. You can read more about birth plans on our factsheet Consenting to treatment.

Your midwife and doctor should provide you with information and personalised discussions to help you make informed choices about your care.

When you make your decision, your midwife should support you. They should listen to you and respect what you say. They should help you to get the maternity care you choose.

If you are struggling to find this support, contact the Director or Head of Midwifery at your hospital. If you don't know the details for the Head of Midwifery, you can ask your midwife and/or the Patient Advice and Liaison service (PALS) (in England and Wales) to put you in touch. The Trust website will have a page with PALS details on it. If you are worried, you can look these details up in case you need them.

The Nursing and Midwifery Code says that all midwives must treat people as individuals and respect and uphold their rights. Your midwife is your advocate. They should support you even if your decision doesn't fit the hospital or birth centre's guidelines.

You may want to choose a hospital or birth centre in another area, for example to be near family support. Or you may need to change to a Trust if your circumstances change, for example if you move to a new area during your pregnancy.

If you move, you can book with a hospital or birth centre in your new area for care. You can do this directly by looking on the hospital's website or asking its maternity team for the self-referral form. Alternatively, your GP in your new area can help. You should be able to do this even if you are very late in your pregnancy. You can also ask to book with the home birth team, although they may have a limit on numbers of people they can book or how late they can accept bookings, depending on how they are staffed.

If you are having trouble booking for care after a move, you can contact us for support.

If you are told that you cannot choose the hospital or birth centre you want because you do not live in the right area, you can ask for an exception to be made. Ask:

Even if their policy says you cannot use the services you have asked for, you can ask them to look at the reasons why you want this hospital or birth centre. They need to give you a good reason if they say no.

Wherever you give birth, your postnatal care will be provided in your home area.

Many NHS Trusts now offer only online video tours, photographs or leaflets about their maternity wards and birth centres. These can help you familiarise yourself with the maternity unit. You do not have a right to an in-person tour.

However, if you have a disability or health condition that means you may need reasonable adjustments, ask to visit the hospital or birth centre so that you and the healthcare professionals working with you can plan ahead.

You might want to look at physical adjustments that will be needed, such as a hoist. If you have a visual impairment, the position and nature of the lighting could be important. Autistic people often want to visit ahead so that they know what to expect and can ask for changes that will make their birth experience easier. The key is that everyone is different so you need to visit in order that you and the healthcare team can plan your individual care.

You have the right to ask for a water birth. The hospital or birth centre may have rules about who can have a water birth but these are not legal rules. You can ask how many rooms have a pool in the birth centre or hospital.

If your care team has concerns about whether a water birth is safe, they should offer you a respectful discussion on the risks and benefits in your situation so that you can make an informed decision.

The hospital or birth centre should only say that you cannot access a water birth if they have a good reason based on clinical evidence.

Your midwife and doctor should also help you consider other options, such as using water for pain relief in labour but not for the birth itself.

If you choose a water birth at the birth centre or hospital, you may not be able to access a pool if there is not one free when you arrive. If you are unsure whether a pool will be available, some people decide to hire their own pool for use at home and then transfer when they are ready. If you have a home birth, you can buy or hire a pool to use at home.

Mental capacity means that you can understand the choice you need to make about treatment and can make a decision.

In law, everyone has mental capacity unless it can be shown that you do not.

Very rarely, someone may not be able to give consent to treatment because they are unable to make a decision that they need to make, even when it is very clearly explained and they are given lots of support.

It is very rare to not have mental capacity.

The people caring for you cannot say you do not have mental capacity simply because you do not agree with them.

Most people do not have to pay for their care. The NHS provides free care to those who are 'ordinarily resident' in the UK. If you are not 'ordinarily resident' then you may have to pay for your care. If this applies to you, then this includes maternity care in hospital, in the community and at home. Your NHS Trust must tell you if you will be charged for your care.

Even if you have to pay for your care and cannot afford to do so, you must still be given maternity care. You cannot be told that you have to wait until you can pay.

The rules about who has to pay for care, and how charging works are very complicated.
Guidance giving you the choice of where to give birth
The 2016 Better Births report for NHS England set out that women should be able to decide where they want to give birth; whether this is at home, in a midwifery unit or in an obstetric unit. This also applies to birthing people who do not identify as women.

The other nations of the UK have the same expectations of maternity services in their areas. Here is their guidance:
Guidance on home births
The legal position is that you have the right under Article 8 of the Human Rights Act to a private and family life which includes the right to choose where you give birth and who is present.

However, this is a qualified right which means that the rights can be restricted where there is a legitimate aim such as protecting the health of others, and the restriction is 'proportionate'.

This means that the Trust should only suspend their home birth service if they have looked at all the options for keeping it going including using local Independent Midwives or bringing back retired midwives to supplement their team, and looking at alternative ways to transfer into hospital if the ambulance service is under pressure (this last realistically applies only in times of severe crisis such as a pandemic).

The UK's guidance is set out in:

In 2016 the NHS Ombudsman accepted that an NHS Trust that suspended its home birth services and refused to make contingency plans was acting unreasonably. They were told to start providing the service again and to work with other Trusts to provide support for home birth in the meantime.
The Nursing and Midwifery Council Code
The Nursing and Midwifery Council Code sets out professional standards of behaviour for nurses, midwives and nursing associates in the UK. It says that midwives need to put the interests of people using maternity care first.
About Birthrights
Birthrights factsheets give you information about your human rights when you are pregnant and giving birth.

Birthrights champions respectful care during pregnancy and childbirth by protecting human rights. We provide advice and information to women and birthing people, train doctors and midwives, and campaign to change maternity policy and systems.

We are a charity, independent of the government and the NHS.
Disclaimer: Our factsheets provide information about the law in the UK. The information is correct at the time of writing (May 2021). The law in this area may be subject to change. Birthrights cannot be held responsible if changes to the law outdate this publication. Birthrights accepts no responsibility for loss which may arise from reliance on information contained in this factsheet. Birthrights has provided links to third party websites where these may help provide relevant further information. Birthrights takes no responsibility for the contents of linked websites and links should not be taken as an endorsement.
Do you work with pregnant women and birthing people?

Our training equips doctors, midwives and other birth workers with knowledge of the law and human rights principles, an understanding of how to apply it in practice, and the ability to communicate effectively with women and birthing people in a way that upholds their human rights. We offer a 10% discount to multidisciplinary teams.

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Can I choose where to give birth? Yes. You have the right to choose where you give birth. You can choose to give birth in a hospital, in a birth centre, or at home. A birth centre is a maternity unit that is run by midwives.

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Written by Rebecca Dekker, PhD, RN and Anna Bertone, MPH on June 4, 2020.

Get our two-page handout on
Pitocin® During the Third Stage
to use in your informed
decision making!!

The third stage of labor, or placental stage, begins after the baby is born and ends after the birth of the placenta (sometimes called the "afterbirth"). It follows the first two stages of labor, which you can think of as the dilation (or opening) stage and the pushing stage. In practice, there are three main approaches to care for the birth of the placenta (Begley et al. 2019):

Expectant management is also called physiological, conservative, passive, "watchful waiting," or "hands-off" management. This approach to caring for the third stage of labor is popular in some European countries, New Zealand, and in midwife-led births in Ireland, the United Kingdom (U.K.), and the United States (U.S.). The care provider waits while the birthing person's uterus continues to contract after the baby is born. These contractions cause the placenta to gradually separate from the uterus and then the placenta is pushed out or birthed with the aid of gravity.

With the expectant management approach:

Care providers do not give Pitocin® (a synthetic form of the hormone oxytocin) or another medication that causes the uterus to contract (called a uterotonic) to prevent heavy bleeding before it occurs. Instead, they closely monitor the mother after birth and treat excess bleeding with a uterotonic medication if it occurs. Sometimes providers skilled at expectant management will take actions to support the birthing person's natural release of oxytocin, for example through immediate skin-to-skin contact, encouraging opportunities for breastfeeding/chestfeeding or another form of nipple stimulation, and ensuring a warm, calm, private birth environment.

Care providers do not clamp or cut the umbilical cord until the placenta is birthed, or at least until the cord has stopped pulsating (or has "gone white").

Care providers do not use traction (controlled pulling) on the umbilical cord, although some providers do use gentle traction once the placenta is visible in the vagina ready to be birthed.

Active management is also called "hands-on" management, where the provider uses different interventions to try to prevent severe blood loss after birth, known as postpartum hemorrhage (PPH). This management approach came about in an attempt to reduce PPH, which is the leading cause of maternal deaths in countries defined as "low-income" by the World Bank, and accounts for more than a quarter of all maternal deaths globally (Vogel et al. 2019). The U.S. Centers for Disease Control (CDC) estimates that PPH accounts for about 11% of pregnancy-related deaths in the U.S. Surveys from the U.S. (Schorn et al. 2017) and the U.K. (Farrar et al. 2010) have found that physicians are much more likely than midwives to "always" or "usually" use active management.

With traditional use of active management:

Care providers give Pitocin® in the third stage or another uterotonic drug just before, with, or after the birth of the baby to help the uterus contract.

Care providers clamp the umbilical cord early, before the cord has stopped pulsating.

Care providers use controlled traction on the umbilical cord with counter-pressure on the uterus to aid the birth of the placenta.

Mixed management is sometimes called "combined" management. It is a mixture of some of the components from expectant management and some of those from active management.

There are many variations, but one example of mixed management might include giving Pitocin® in the third stage, waiting to clamp the umbilical cord until it has stopped pulsating, and remaining "hands-off" as the birthing person expels the placenta with the aid of gravity.

It's important to understand that while the traditional definition of active management is a package of three components (giving a uterotonic, early cord clamping, and controlled cord traction), more modern definitions of active management focus mostly on giving the uterotonic, and could be described as mixed management. In other words, routine early cord clamping and controlled cord traction are no longer considered essential components of active management (WHO, 2019; Hofmeyr et al. 2015).

A small qualitative study found that pregnant people are often given little or no information from their care providers about their options for birthing the placenta (Reed et al. 2019). When care providers did offer information, it tended to reflect their own preferences or usual practice style rather than a true discussion of options. This is concerning, because pregnant people express diverse preferences for the third stage of labor-some consider expectant management a safer process and an essential element of natural (physiologic) birth, while others consider active management to be the safe route that prevents complications and helps you avoid further interventions.
In this Evidence Based Birth® Signature Article, we ask: Who is at lower risk for severe bleeding after birth and who is at higher risk? What is the evidence for expectant versus active or mixed management and what are the potential benefits and risks of each approach?
How Has Care During the Third Stage of Labor Changed Over Time?

Historically, the focus was on treating postpartum hemorrhage (PPH) when it occurred, not intervening in the third stage of labor an attempt to prevent PPH. Midwives treated PPH after-the-fact with vaginal packing or applying hot vaginal douches, with limited success.

The first effective treatment for PPH came into use around the 16 th century (Chamberlain, 2006). Midwives discovered that extracts of ergot (a fungus) could cause the uterus to contract and stop excessive bleeding. So, if a woman appeared to be losing too much blood after birth, she would drink extracts of ergot as a "labor tea" to stop the bleeding. Since ergot worked by causing the uterus muscles to contract, it was the first uterotonic drug used to treat PPH.

Oliver Prescott, a physician in Massachusetts, published an official dissertation on the use of ergot to treat PPH in 1813. About 100 years later, in 1912, Dr. Barry Hart of Edinburgh made the case that ergot should be used before PPH, as a way to prevent excessive bleeding before it occurs (Chamberlain, 2006). In other words, he proposed active management of the third stage of labor by giving birthing people a uterotonic drug to prevent PPH. This idea caught on, especially in the 1950s, after studies found a reduction in PPH with the routine use of ergot injections in the third stage of labor. However, ergot was also linked to side effects in some people, including high blood pressure, nausea, vomiting, headache, and abdominal pain.

Today, the World Health Organization still recommends ergot preparations as an effective uterotonic drug for birthing people without high blood pressure disorders (WHO, 2018). But in settings where multiple uterotonic options are available for active management of the third stage of labor, the WHO recommends synthetic oxytocin over the other options.

Oxytocin and Synthetic Oxytocin (Pitocin®) in the Third Stage of Labor

Synthetic oxytocin first came into use in the 1950s, much later than ergot. Soon after, in the 1960s, active management (uterotonic drug plus immediate cord clamping and controlled cord traction) became popular in many hospital settings to try and prevent postpartum hemorrhage (Aflaifel and Weeks, 2012).

The hormone oxytocin was discovered in 1906 when Sir Henry Dale of London found that an extract from the human pituitary gland, a pea-sized structure at the base of the brain, caused uterine contractions in a pregnant cat (Magon and Kalra, 2011). He named the hormone " oxytocin" after the Greek words for " quick birth." Then, in 1953, a New York biochemist named Vincent du Vigneaud published the chemical structure of oxytocin, work for which he received the 1955 Nobel Prize in Chemistry (du Vigneaud et al. 1953). Research on oxytocin in the early 1950s used extracts from cow and pig pituitary glands. Today, commercially sold oxytocin is prepared synthetically in laboratories.

Pitocin® , a synthetic form of oxytocin, is commonly used in clinical practice to start (induce) and speed up (augment) labor, as well to help the uterus contract after birth in active management. In some countries, such as Australia, they use an equivalent drug called Syntocinon® . Pitocin ® and Syntocinon ® are brand names of synthetic oxytocin, while the generic form of the drug is simply called "oxytocin."

Other uterotonics are also used for PPH prevention, including carbetocin, prostaglandin analogues such as misoprostol, ergot alkaloids, or combinations of these (oxytocin plus ergometrine, or oxytocin plus misoprostol) (Vogel et al. 2019). This Evidence Based Birth® Signature Article focuses on synthetic oxytocin (Pitocin ®) as the uterotonic in the third stage of labor.

How Do Oxytocin and Pitocin® Work in the Body?

To understand why uterotonics are used in management of the third stage of labor, it helps to understand more about how oxytocin and Pitocin ® work in the body. Below, we refer to the body's own naturally produced (endogenous) oxytocin as oxytocin and synthetic oxytocin as Pitocin®.

In 2019, researchers published a systematic review of 20 studies that measured oxytocin levels at different points during pregnancy and childbirth (Uvnäs-Moberg et al. 2019). During pregnancy, they found that blood levels of oxytocin gradually rise, increasing by 3 to 4 times. Levels of oxytocin rise even more in labor, when pulses of the hormone become larger and more frequent to contract the uterus and help the progress of labor. The maximal frequency of pulses was found to be 3 pulses per 10 minutes (not tied to the frequency of contractions) just before the birth. There is a large pulse of oxytocin during the actual birth when the fetal head emerges, and pulses continue during the third stage of labor with the birth of the placenta.

The presence of the body's own oxytocin or receiving Pitocin ® is critical to preventing PPH in the third stage of labor. After birth, oxytocin or Pitocin ® continues to cause the birthing person's uterus to contract in order to expel the placenta. With each contraction, the movement shears the placenta from the uterine wall (OpenStax, Anatomy & Physiology, 2016). There is an upward "wave of separation" that causes the upper part of the placenta to detach last (Funai et al. 2019). When it detaches, this leaves a placenta-sized wound on the inside of the uterus. Without effective contractions, the uterine blood vessels are left wide open and enormous amounts of blood can be lost very quickly. But when the birthing person's oxytocin or Pitocin ® continues to cause contractions, this causes the uterus to clamp down with pressure on the bleeding blood vessels where the placenta was attached and stop the bleeding at the placenta wound site-helping to prevent PPH.

How Are They Similar and How Are They Different?

Another difference is that when Pitocin ® is given in high doses during labor, it can cause more frequent, longer, and more painful contractions. Researchers have found that giving Pitocin ® infusion in doses up to 9 milliunits (mU) per minute leads to similar levels in the blood as seen with physiologic labor, whereas doses between 10-16 mU per minute raise levels to double those of physiological labor (Uvnäs-Moberg et al. 2019). The optimal dosing regimen for giving Pitocin ® in practice is controversial; UpToDate ® guidance for clinicians states that most protocols limit oxytocin infusion during labor with a live fetus in the third trimester to no more than 40 mU/minute (Grobman et al. 2019). In the future, we may see more research on giving Pitocin ® infusion in pulses during labor, which would be more like the body's own way of releasing oxytocin.

Oxytocin in the body (both natural and synthetic) causes the uterus to contract by binding with oxytocin receptors on the cell surface. When there is a lot of oxytocin, the body compensates by decreasing the number of oxytocin receptors to maintain body equilibrium (balance). So, prolonged exposure to Pitocin ® in labor may lead to a reduction in the number of oxytocin receptors, called receptor desensitization or oxytocin receptor down-regulation. This is less likely to happen in physiologic labor and birth (with the body's own oxytocin) because the oxytocin is released in pulses and then rapidly broken down by an enzyme so that there is very little (if any) oxytocin left in the bloodstream between pulses (Fuchs & Fuchs, 1984). Getting that break from oxytocin exposure protects against receptor desensitization, helping to keep contractions effective.

What Is Postpartum Hemorrhage?

Postpartum hemorrhage (PPH) is bleeding too much after birth. When PPH occurs in the first 24 hours after birth, it is sometimes called primary or early PPH (ACOG, 2017). When hemorrhage occurs from day two up until 12 weeks after birth, it is called secondary, late, or delayed PPH. This Evidence Based Birth ® article focuses on primary PPH.

It is helpful to remember "the 4 Ts" that can cause postpartum hemorrhage (ACOG, 2017):

Tone

Loss of muscle tone in the uterine muscle is also called uterine atony. Atony literally means "without tone." Uterine atony is a serious condition responsible for 70%-80% of all PPH. Since it is the most common cause of PPH, care providers should suspect it first, before the other possible causes. If the birthing person's uterus lacks tone, that means it is not able to contract enough after birth to stop blood loss. The reason Pitocin ® is given during the third stage of labor in active management is to help ensure the uterus will contract and have tone to prevent bleeding too much. In cases where tone is lacking, Pitocin ® treats the atony and promotes uterine tone.

Labors that are prolonged or rapid (with very strong contractions) can also lead to uterine atony and increase the risk of PPH.

Other factors that can decrease tone in the uterus besides exhaustion of the uterine muscles include infection, having a large uterus (e.g., from high levels of amniotic fluid, a large baby, or multiples), having an unusually shaped uterus (e.g., from non-cancerous growths in the uterus called fibroids), or taking drugs that relax the uterus to prevent preterm labor (Association of Ontario Midwives, 2016).

Trauma

Trauma in birth can be physical or psychological. In this context, trauma refers to physical injury-such as uterine rupture; tears to the cervix, vagina, or perineum; and episiotomy-that can cause PPH. Tears must be repaired in order to stop the bleeding. Pitocin ® after birth with active management does not directly reduce blood loss caused by tissue damage (these tears must be repaired to stop the bleeding), but it reduces overall blood loss after birth, which becomes more beneficial when someone is losing blood from injury.

Tissue

When portions of the placenta or membranes are left behind in the uterus they can prevent adequate contractions and contribute to PPH. The tissue must be removed to stop the bleeding. Having disorders of the placenta can put the birthing person at increased risk for leaving tissue behind (Association of Ontario Midwives, 2016). For example, placenta accreta is a serious condition where the placenta grows too deeply into the uterine wall, most often due to scarring from a prior Cesarean or other uterine surgery.

Thrombin

The "T" for thrombin reminds providers to evaluate if the mother is able to clot normally. If not, she may require treatment to help with blood clotting. This is thought to be the least common reason for PPH, causing about 1% of cases (Association of Ontario Midwives, 2016). Coagulation defects (clotting disorders) can cause a PPH or be the result of a PPH. They can be pre-existing (e.g., hemophilia), or acquired in pregnancy or labor (e.g., having low platelets, or clotting abnormalities with severe preeclampsia) (Evensen et al. 2017). Any of the previous three "T"s can become a clotting problem due to large losses of blood if left untreated long enough.

What is the Definition of Primary Postpartum Hemorrhage?

There is no standard definition of PPH that is used in the research and in professional guidelines around the world. Some amount of blood loss is normal and expected after childbirth. However, too much blood loss is a childbirth emergency that can be life threatening. The answer to the question of where to draw the line between normal, physiologic blood loss and excessive blood loss (i.e. postpartum hemorrhage) remains controversial.

Since the 1950s, PPH after vaginal birth has traditionally been defined as ≥500 mL blood loss within 24 hours of birth, and severe PPH has been considered ≥1000 mL blood loss (WHO, 2012). Until recently, this definition for PPH was applied to all birthing people regardless of their health status and whether or not they suffered any harmful effects from their blood loss after birth.

Postpartum hemorrhage is now being redefined based on research showing that healthy birthing people are usually unharmed by blood loss up to 1000 mLs (Anger et al. 2019). For perspective, blood loss around 500 mL is similar to a routine blood donation, a loss of about 2 cups of whole blood, which is usually well tolerated by healthy people. The blood that is lost after birth is sometimes also diluted with urine and amniotic fluid. In addition, there is an expansion of blood volume that occurs during pregnancy (by about 1250 mL) that helps to protect mothers against harmful effects of blood loss after birth (Erickson et al. 2017).

Harm from Blood Loss in the Third Stage of Labor Depends on the Individual

A review by Erickson et al. included two randomized trials where researchers randomly assigned (like flipping a coin) participants to expectant versus active management. None of the participants had received any Pitocin ® to start or speed up labor. They found that the average blood loss (calculated by weight) was just over 500 mL among the people who did not receive Pitocin ® after birth, and closer to 400 mL among those who received the Pitocin ® with active management. So, it's possible that blood loss around 500 mL could be considered normal or physiologic blood loss after childbirth. Accordingly, a joint consensus statement of midwifery organizations in the United States included "Results in physiologic blood loss" as one of the components of normal physiologic childbirth (ACNM, MANA, NACPM Consensus Statement, 2012).

On the other hand, it's important to consider that individuals vary in when they will experience harm from blood loss. Some people experience signs and symptoms before losing 500 mL of blood and others can lose 1000 mL or more of blood after birth without clinical effects. Birthing people with anemia, low body mass, and those who have decreased blood volume (from dehydration or preeclampsia, for example) are more likely to feel the effects of losing even a few hundred mL of blood (Association of Ontario Midwives, 2016).

The U.S. reVITALize definition for early PPH accounts for the fact that the clinical consequences of blood loss vary by individual. The definition is formally endorsed by the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Family Physicians (AAFP), the American College of Nurse-Midwives (ACNM), the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), and the Society for Maternal-Fetal Medicine (SMFM).

They now define early PPH to be (1) blood loss of ≥1000 mL or (2) any amount of blood loss that is accompanied by signs/symptoms of hypovolemia (decreased blood volume) within 24 hours following a vaginal or Cesarean birth. Signs/symptoms of hypovolemia may include fast heartbeat, low blood pressure, fast breathing, low urine output, unhealthy paleness, dizziness, or altered mental state. When blood loss exceeds 500 mL after a vaginal birth or 1,000 mL after a Cesarean, it should trigger increased supervision, a rapid and thorough evaluation to identify the cause of the bleeding, and potential interventions as clinically indicated, but it does not make the diagnosis of PPH alone without additional signs/symptoms of decreased blood volume (ACOG, 2017).

How Do Care Providers Assess Blood Loss in the Third Stage of Labor?

Visually estimating how much blood has been lost is the most common method of determining blood loss volume after birth, where the care provider looks at the amount of blood lost and tries to estimate its volume (Diaz et al. 2018). Research has consistently shown that care providers tend to over- or under-estimate blood loss volume with their visual estimates. The same holds true across provider types and birth settings. Smaller volumes of blood loss tend to be overestimated and larger volumes of blood loss tend to be underestimated (Hancock et al. 2015). One study author made the observation that "estimates simply reflected teaching about what constitutes average blood loss at birth" (Razvi et al. 1996). So, providers might see what they expect to see based on their training about typical blood loss after birth. There are conflicting findings on whether years of experience and additional training can improve visual estimation skills.

A more precise method of assessing blood loss volume is using direct blood collection and measurement, often referred to as "quantified blood loss." With this method, all of the blood that is lost in the third stage of labor (except the placenta and membranes) is funneled out from under the birthing person's buttocks and into a collection device such as a bag, a bedpan, or an absorbent pad, where the blood can be measured.

When blood loss is actually measured rather than visually estimated, there is less potential for introducing bias from the diagnosing clinician. Racial bias (i.e., racism) in PPH assessment is a major concern, because poor recognition of PPH delays treatment. A large study with over 360,000 participants with PPH in U.S. hospitals found that non-Hispanic Black birthing people were at the highest risk for severe illness from PPH, and at five times higher risk for death compared to non-Hispanic White birthing people (Gyamfi-Bannerman et al. 2018).

Quality improvement projects to reduce PPH usually include quantified blood loss as part of a larger safety bundle to improve readiness, recognition and response to PPH. In this way, using quantified blood loss helps improve communication between providers. A recent study on a large quality collaborative in California found that hospitals using the PPH safety bundle with support from outside mentors were able to reduce severe maternal complications from PPH (Main et al. 2017).

Although quantified blood loss is a more accurate and objective way to assess blood loss volume, it may not be practical in all birth settings. And currently, there is no evidence from randomized trials that measuring blood loss results in better clinical outcomes compared to visually estimating blood loss. A Cochrane review found only two trials evaluating methods for estimating blood loss after vaginal birth (Diaz et al. 2018). There wasn't enough evidence to recommend direct measurement of blood loss over visual estimation. However, the promising findings from the large quality improvement collaborative in California suggest quantified blood loss may offer benefits over visual estimation.

In addition to blood loss volume, care providers also assess the speed of blood flow and the birthing person's response to the blood loss, including their pulse and blood pressure (Hancock et al. 2015). A review of the research concluded that these are also important factors in early diagnosis and treatment of PPH.

How Common Is Primary Postpartum Hemorrhage?

Estimates vary widely, depending on which definition of PPH is used. Randomized trials have found rates of blood loss >1000 mL ranging from 0.9%-2.9% with a routine uterotonic given in the third stage of labor versus 2.4%-4.8% without a routine uterotonic (Begley et al. 2019; Salati et al. 2019).

In the United States (U.S.), the rate of PPH >500 mL after vaginal birth (or 1000 mL after Cesarean birth) was 3% in a large study of 8.5 million hospital births between 1999 and 2008 (Kramer et al. 2013). During the study period, the overall rate of PPH stayed around 3%. However, the rate of severe PPH that led to blood transfusion, surgical removal of the uterus, or surgical repair of the uterus rose from 1.9 to 4.2 per 1000 from 1999 to 2008.

A recent study from the Netherlands looked specifically at PPH >1000 mL among 2.5 million people who gave birth between 2000 and 2013 (Van Stralen et. al 2016). They found that PPH rose significantly from 4.1% in 2000 to 6.4% in 2013.

Why is the Rate of Postpartum Hemorrhage Rising in Recent Years?

Australia, Canada, the U.K., and the U.S. have all reported a recent increase in the rate of PPH, and researchers aren't sure why (Kramer et al. 2011). They speculate that it may relate to an increase in mothers with risk factors for PPH: more people giving birth after Cesarean, more multiple pregnancies, and an increase in induction, augmentation, and epidural use. However, there is very limited evidence to support these possible explanations.

Researchers in Canada looked back at over 100,000 births to single babies between 1978 and 2007 to try and explain their recent rise in PPH (Kramer et al. 2011). All of the births took place at a single hospital in Montreal. Hemorrhage was defined as >500 mL for vaginal births and >1000 mL for Cesarean births. Blood loss was based on the obstetrician's visual estimates and management approach varied (active versus expectant).

Overall, 2.3% of the participants had a PPH during the study period, and the rate rose between 1978 and 2007. In addition to the increase in PPH, there was also an increase in labor induction, labor augmentation, and prior Cesarean section over the study period. The researchers concluded that these three risk factors (induction, augmentation, and prior Cesarean) appeared to largely explain the increase in PPH.

However, another study from Australia was not able to explain their rise in PPH by taking risk factors into account. PPH was defined as >500 mL after a vaginal birth or 750 mL after a Cesarean birth. Again, blood loss was based on visual estimates, and provider management approaches varied. Out of over 700,000 births between 1994 to 2002, the rate of PPH increased even after considering the birthing person's age, prior Cesarean section, multiple pregnancies, induction/ augmentation of labor, and epidural use (Ford et al. 2007).

More research is needed, using a standardized definition for early PPH, because we do not yet have solid evidence on why the rate of PPH is increasing.

What Factors Increase the Risk of Postpartum Hemorrhage?

First, it's important to point out that anyone can experience excessive blood loss after birth, even if they have no known risk factors for PPH. This is why many professional organizations recommend active management with the routine use of Pitocin ® for everyone, regardless of individual risk factors for PPH.

However, studies have identified many factors linked to increased risk of blood loss ≥1,000 mL. It may be useful to discuss these risk factors with your care provider and consider how they apply to your unique situation when deciding between active and expectant management for the third stage of labor. Some of these risk factors can be known before the birth, and some can only be known after the birth.

Table 1 lists risk factors for postpartum hemorrhage defined as blood loss ≥1000mL and/or blood transfusion, surgical repair, or surgical removal of the uterus. The data come from population studies in the U.S., the Netherlands, Canada, Norway, Israel, and Sweden (Association of Ontario Midwives, 2016, Table 2, Page 9; Sheiner et al. 2005; Kramer et al. 2013; van Stralen et al. 2016; Oberg et al. 2014).

Table 1. Factors Linked to Increased Risk of Blood Loss ≥1,000 mL

What Is the Normal Length of the Third Stage of Labor?

Providers are careful to monitor the time that passes after the birth and before the placenta is expelled because a longer third stage of labor is linked to increased risk of PPH. When the placenta is not expelled after birth and remains in the uterus, it is diagnosed as a retained placenta and is often manually removed. Manual removal of the placenta is an invasive procedure that can be painful. The care provider puts on a sterile glove and inserts a hand through the cervix and into the uterus. The provider's hand moves in a careful up and down motion to sweep behind the placenta and manually separate it from the wall of the uterus.

There are different professional opinions about what length of the third stage of labor is "normal" versus a third stage of labor that is abnormally long and would benefit from intervention.

A large study with nearly 13,000 single vaginal births found that, on average, 50% of placentas were birthed within 6 minutes and 97% were birthed by 30 minutes (Combs and Laros, 1991). In this study, most of the birthing people received active management of the third stage of labor. Factors linked to a longer third stage of labor in this study included preterm birth (a major risk factor), giving birth lying in bed (as opposed to upright), preeclampsia, augmented labor, and being a first-time mother.

In a review that looked at people who had expectant management of the third stage of labor, researchers concluded that it takes longer to birth the placenta with expectant management: 80% of mothers birthed their placenta by 30 minutes and 98% by 60 minutes (Weeks, 2008).

Recent meta-analyses of randomized trials (multiple trials combined into one large study) have not found a significant difference in the length of the third stage of labor with active versus expectant management (Begley et al. 2019; Salati et al. 2019). These meta-analyses concluded that there is low to very low- quality evidence that active management or Pitocin ® alone may make little or no difference to the average length of the third stage of labor. However, earlier data (mentioned above) suggest that the third stage of labor may be longer with expectant management.

UpToDate ® guidance for clinicians recommends that providers take into account how the third stage of labor is managed when they are deciding when to offer intervention in the third stage of labor. They say that the waiting period can be extended for expectantly managed third stages of labor and that "waiting as long as 60 minutes [with term births] is reasonable if an intervention can be promptly and successfully initiated if the patient begins to bleed" (Weeks et al. 2019).

In the U.K., the National Institute for Health and Care Excellence (NICE) guidelines define a prolonged third stage of labor as not completed within 60 minutes of the birth after expectant management and within 30 minutes of the birth with active management (NICE, 2019). They recommend a change from expectant to active management if the birthing person has PPH or the placenta is not expelled within one hour of the birth of the baby.

What Is the Evidence on Management of the Third Stage of Labor?

Randomized Trials Comparing the Active Management Package to the Expectant Management Package

A recent Cochrane review examined four randomized trials with nearly 5,000 participants who were assigned to active versus expectant management in hospital settings (Begley et al. 2019). Three of the studies were from the United Kingdom and one was from Ireland.

It is worth noting that the care providers who attended the births in these studies were more familiar with active management than expectant management. Some of the participants were considered at low risk for excessive bleeding after birth and some were at higher risk (i.e. had more risk factors for bleeding). Many of the participants in these studies had their labors induced or augmented.

What did they find?

Benefits of Active Management of the Third Stage of Labor

Overall, there was high-quality evidence that active management reduced the average amount of blood loss at birth (by around 80 mL).

It's important to note, however, that only one of the four studies actually measured blood loss (the rest estimated it), and are therefore open to mistakes in measurement as well as possible bias from lack of blinding. In other words, care providers were not blinded to participants' group assignments (active versus expectant) and may have assessed blood loss based on their beliefs about which birthing people were at greater risk of losing more blood.

Since visual estimations of blood loss can be subjective and unconsciously affected by a person's beliefs, the Cochrane authors also reported the birthing person's hemoglobin (Hb) less than 9 g/dL at 24 to 72 hours as a hard outcome relating to blood loss. They found that fewer mothers had anemia after birth with active versus expectant management (4% versus 7%; low-quality evidence). However, they point out that the average difference between groups may not be clinically important, as routine blood donation reduces Hb levels by a similar amount without ill effects in healthy women, and levels may rise within a few days after birth.

Active management reduced blood loss greater than 500 mL at birth (5% of participants lost >500 mL with active versus 15% with expectant management; moderate-quality evidence).

As far as blood loss ≥1,000 mL at birth, active management also showed benefits; however, the Cochrane authors called this finding "uncertain" because the evidence was considered very low-quality. The absolute risk of blood loss ≥1,000 mL at birth was 0.9% of people with active versus 2.4% of people with expectant management (three randomized trials). To put it another way, there would be one fewer PPH ≥1,000 mL after birth for every 66 people who had active management.

On a side note, research on planned home birth in the U.S.-where expectant management is routine care-has found that a similar number of people are estimated to lose greater than 500 mL of blood (15.5%) and greater than 1000 mL of blood (4.8%) (Cheyney et al., 2014).

In the Cochrane review, fewer participants assigned to active management in the trials required a blood transfusion (1% with active versus 3% with expectant management; low-quality evidence), and far fewer birthing people received therapeutic (or "rescue") uterotonic medications within 24 hours of the birth (4% versus 21%; moderate-quality evidence).

They found no difference in the number of babies admitted to newborn care units or the number of babies with jaundice requiring treatment between the participants who received active versus expectant management. There was also no evidence that active management makes a difference in the need to remove the placenta manually or the average length of the third stage of labor.

Downsides of Active Management of the Third Stage of Labor

In addition to the benefits for blood loss prevention, there were also some downsides to active management for mothers and babies ( low-quality evidence). Birthing people who received active management had an increase in blood pressure (3% versus 1%); however, this was probably due to ergometrine-containing preparations, not Pitocin ®. With active management there was more vomiting after birth (7% versus 3%); more afterpains requiring pain medication (5% versus 2%); and a higher rate of return to hospital for bleeding (3% versus 1%).

The increase in the number of people returning to the hospital with bleeding is concerning-for every 65 people who had active management, one returned to the hospital because of bleeding. The authors think that the increased risk of late bleeding might have been due to shreds of tissue left behind after cord traction.

Not surprisingly, active management reduced the average birth weight of the baby (by about 80 grams; moderate-quality evidence) due to lower blood volume from early cord clamping. This effect could probably be avoided by changing the active management approach to include delayed cord clamping (waiting until the cord stops pulsating).

None of the included studies reported any maternal or newborn deaths.

The Cochrane authors looked separately at the risk of blood loss ≥1,000 mL in two trials with nearly 3,000 participants considered to be at low risk of PPH. These two studies varied in their specific criteria for "low-risk." Both of them excluded birthing people for a history of hemorrhage; having given birth >5 times; anemia during pregnancy; a placenta that covered the cervix or separated from the uterine wall before birth; forceps or vacuum use; epidural use; and medical conditions that could increase their risk of bleeding after birth, such as heart disease or high blood pressure. All of the participants in the studies were planning to give birth vaginally to single, head-down babies. They found no evidence that active management lowered the risk of blood loss ≥1,000 mL in people at low risk for bleeding.

None of the studies looked specifically at people at high risk for bleeding after birth.

Conclusion

In conclusion, the Begley et al. (2019) Cochrane review found both benefits and harms to active management. Active management reduced the risk of severe blood loss and anemia after birth in a group that included both people at lower risk for bleeding and those at higher risk for bleeding. However, it also increased the need for pain medication for afterpains and increased the risk of excess bleeding following hospital discharge.

It is possible that the benefits of reduced blood loss can be achieved with less harm by making changes to the active management approach. These changes could include using a uterotonic medication that does not raise blood pressure (such as Pitocin ®), improving skill or eliminating cord traction, and delaying cord clamping.

The authors recommend that pregnant people be given information on both the potential benefits and harms of active management to support informed choice. Unfortunately, the evidence on which management approach reduces the risk of severe blood loss >1,000 mL is very low quality, so it's difficult to draw firm conclusions, especially among people at low risk of PPH. The quality of the evidence is higher showing that active management reduces average blood loss (by around 80 mL) and the rate of blood loss >500 mL, but these outcomes are not as clinically important as a reduction in blood loss ≥1,000 mL. If someone chooses expectant management, it is important that they have a uterotonic drug available if excess bleeding occurs.

Randomized Trials Comparing the Active Management Package to Different Mixed Management Packages

The Begley et al. (2019) Cochrane review also looked at four trials of active versus mixed management of the third stage of labor. Unfortunately, all of the mixed managements differed, so they were not able to draw firm conclusions on any of the approaches.

Out of the four trials on mixed management, only one was considered to be high quality. This study included healthy pregnant people in Sweden between 34 and 43 weeks with single, head-down babies (Jangsten et al. 2011). None of the participants had experienced a previous PPH, had preeclampsia, or had given birth >5 times. However, the study did include people with risk factors for PPH. About 4% of each group had a prior Cesarean, 40% had an epidural, and 50% had their labors sped up with synthetic oxytocin.

About 800 people were randomly assigned to active management and 800 people were assigned to mixed management. The active management approach consisted of giving synthetic oxytocin within 2 minutes of birth, immediate cord clamping, controlled cord traction while the birthing person pushed, and uterine massage after birthing the placenta. In comparison, the participants assigned to mixed management received a placebo of IV saline solution instead of the synthetic oxytocin. They had the cord clamped immediately, but did not receive any cord traction during pushing. Again, everyone received uterine massage after the placenta was birthed. All blood loss up to two hours after birth was collected and measured.

Compared with mixed management that used early cord clamping and no uterotonics or cord traction, active management with a uterotonic reduced the use of therapeutic uterotonics within 24 hours of the birth (5% versus 18%). Active management also reduced blood loss of 1,000 mL or more up to two hours after birth (10% versus 17% - surprisingly high rates!), it reduced the length of the third stage by a couple of minutes, and it increased the mother's average Hb levels after birth. This study found that active management was linked to lower pain scores at two hours after birth compared to mixed management without a uterotonic.

Randomized Trials Comparing Pitocin® Versus No Pitocin®

Like Begley et al. (2019), they found that Pitocin ® reduced the risk of blood loss >500 mL and >1000 mL after birth ( low quality evidence). The absolute risk of blood loss >1000 mL was 2.9% of people with synthetic oxytocin versus 4.8% without (five randomized trials). They also found moderate quality evidence that it reduced the use of additional uterotonics as treatment for PPH.
Again, there was no evidence that active management made a difference in the need to remove the placenta manually or the length of the third stage.
Unlike Begley et al. 2019, they found no difference in the risk of receiving a blood transfusion between the birthing people assigned to Pitocin ® versus no uterotonics or placebo. Salati et al. did not examine delayed blood loss (>24 hours to 6 weeks) after birth, so we don't know how that factor compared between groups.

Observational Studies Comparing Active Versus Expectant Management

As we mentioned earlier, the evidence we have from randomized trials comes from settings where the care providers are more familiar with active than expectant management, and where labor interventions, including synthetic oxytocin to augment labor, are extremely common. Researchers have called for more studies to be conducted in areas where providers are familiar with supporting the physiologic third stage, such as the Netherlands and New Zealand, and in settings where routine labor interventions are not the norm (Begley et al. 2019).

We found four retrospective studies (where researchers look back in time at birth outcomes) in the last 10 years that reported rates of PPH and the type of management that was used during the third stage ( Table 2). We were looking for studies that reported the rate of PPH among people who received active management and the rate of PPH among a similar group of people who had expectant management. The studies took place in Ireland (Dencker et al. 2017), England (Homer et al. 2017), New Zealand (Dixon et al. 2013), and Australia (Fahy et al. 2010).

Table 2. Four Retrospective Studies Reporting Rates of PPH and Approach to Third Stage (Expectant versus Active)

These are observational data, not from a randomized trial, so the evidence is lower quality. We can't rule out the presence of factors that bias the results; for example, longer labors are linked to more PPH and more active management (Dixon et al. 2013).

Two of these studies examined PPH by type of third stage management as their primary outcome. They reported the rate of PPH >1,000 mL among low-risk pregnant people to be 0.5% to 3.4% with expectant management and 2.9% to 9.9% with active management.

The results from these observational studies show no increase in blood loss with expectant management. On the contrary, they found that people who had expectant management had a lower risk of PPH, and active management increased the risk of PPH.

The largest study included over 32,000 low-risk pregnant people in New Zealand who received midwife-led care in a variety of birth settings from 2004 to 2008 (Dixon et al. 2013). About half of the participants received expectant management and half received active management. In addition to higher levels of PPH >1,000 (9.9% vs. 3.4%), active management was also linked to more need for manual removal of the placenta (0.7% vs. 0.2%).

Also, they found that the people who had active management and then treatment for excessive bleeding had more blood loss of >500 mL than those who had expectant management and then treatment. This suggests that uterotonic drugs might provide more effective treatment for PPH when there has been no prior routine exposure (leading to receptor desensitization and/or uterine atony).

The quality of evidence from observational studies is not as high as randomized trials; still, these findings raise questions about whether the benefits of reduced blood loss seen in randomized trials apply to pregnant people at low risk for PPH who experience expectant management with a skilled provider after a physiologic birth.

Evidence on Best Practices to Use With Expectant Management in the Third Stage of Labor

Researchers interviewed expert midwives in Ireland (9 midwives) and New Zealand (18 midwives) about the skills they used for expectant management of the third stage of labor (Begley et al. 2012). To be included in the study, the midwives had to use expectant management with at least 30% of their births over the previous two years and have an average PPH rate (defined as >500 mL) with expectant management of less than 4% (which is a very low PPH rate with expectant management).

In general, the expert midwives expressed that their role during the third stage of labor was one of "watchful waiting" and "alert vigilance." Expectant management was only considered appropriate following an uncomplicated labor without epidural or synthetic oxytocin for induction or augmentation. The interviews revealed that the midwives shared many common beliefs about how to best support the physiologic third stage of labor. Some of the important components of expectant management that were identified by these skilled midwives included:

Carefully observe and listen to the birthing person, paying close attention to behavior and feelings:
For example, if the mother describes cramping or a sore back, this alerts the midwife that the placenta may have separated; if the birthing person feels dizzy and unwell, this alerts the midwife to the threat of excess blood loss

Watch for other signs of placental separation, which include a "normal separation bleed," also described as a "single gush" followed by a lengthening of the cord

Foster a birth environment that feels warm, calm, quiet, and safe

Encourage mother-baby attachment by facilitating skin-to-skin contact immediately after birth

Place the baby on the chest in order to encourage it to initiate its own feed, or proactively latch the baby if there is a concern about blood loss or a delayed placenta

Do not rush to clamp the cord

Use truly upright positions and maternal effort to birth the placenta, especially if there is a delay (walking and sitting on the toilet was used often)

Offer the mother food or fluids to replace her energy for the effort required to birth the placenta

Assist with gentle cord-traction by giving "a little lift" or "easing down and out" if the placenta has separated and descended into the vagina

Plan ahead-discuss the birthing person's risk factors for PPH and wishes for the birth; prepare in advance for complications

Some researchers argue that the definition of "expectant management" used in randomized trials is extremely limited and might as well be described as " not active management" (Hastie and Fahy, 2009). This narrow definition of expectant management leaves out most of the elements of physiologic third stage care that midwives believe are important, and therefore the findings from the randomized trials can not be generalized to midwife-led and community birth settings.

Hastie and Fahy propose an alternative to active management that they describe as a holistic approach called "psychophysiological" third stage care. It includes best practices based on scientific theory and midwife expertise. Basically, they explain how environmental factors in the birth environment (such as lack of privacy, bright lights, noise, the presence of strangers) may disrupt the protective hormonal changes that should occur immediately after birth. To optimize a birthing person's psychophysiology, they say that the midwife must act as a guardian so that the mother and baby can experience an undisturbed third stage of labor. Read an interview with the authors here at Lamaze International!

Dr. Sarah Buckley, a New-Zealand-trained family physician and researcher in this field, explains that the fight-or-flight hormones adrenaline and noradrenaline (epinephrine and norepinephrine, also known as catecholamines) can help to keep the birthing person awake and energized to push in the second stage of labor (Buckley, 2020). However, in the third stage of labor, these levels start to fall, and if the mother is cold, shivering, worried, or distracted, continuing high levels of catecholamines can disrupt the beneficial effects of oxytocin.

The baby also requires warm skin-to-skin contact to lower their stress hormones and promote nipple-seeking behaviors. Skin-to-skin contact and breastfeeding/chestfeeding further increase oxytocin levels in both the mother and baby.

In summary, expectant management should be much more than simply doing nothing or "not active management." Providers skilled at expectant management use many techniques to support the birthing person's own naturally produced (endogenous) release of oxytocin.

What Is the Evidence on Breastfeeding/Chestfeeding or Nipple Stimulation to Prevent PPH?

A 2016 Cochrane review that included four randomized trials concluded that there is currently not enough evidence to know whether early suckling or nipple stimulation is effective for reducing bleeding during the third stage of labor (Abedi et al. 2016).

We found one randomized trial on this topic that was too recent to be included in the 2016 Cochrane review (Dashtinejad et al. 2018). This study randomly assigned 108 birthing people in Iran to breast stimulation or synthetic oxytocin in the third stage of labor. None of the participants had their labors induced or augmented. People in the stimulation group received breast pump stimulation (10 min for each breast with a negative pressure of 250 mmHg), while those in the synthetic oxytocin group received an infusion of 30 IU synthetic oxytocin in 1,000 mL of Ringer's serum with a maximum rate of 10 mL infusion per min after birth.

There were no differences in the rate of blood loss >500 mL or anemia between the groups. In other words, breast stimulation worked as well as synthetic oxytocin to prevent bleeding in this study. Moderate to severe after-birth pain was significantly lower in the stimulation group compared to the synthetic oxytocin group (9% versus 74%) and more people in the stimulation group said they were highly satisfied with their care (85% versus 6%). The authors concluded that using breast stimulation is cost-effective and may be considered for women at low risk for PPH.

Interestingly, using nipple stimulation before birth to induce labor may help to prevent excess blood loss after birth. A Cochrane review combined two randomized trials from 1993 with 300 total participants and found significantly less PPH (not defined) after birth among those who had stimulated their nipples to induce labor (Kavanagh et al. 2005). The participants had stimulated one nipple at a time for one hour per day for three days. The rate of PPH was 0.7% with nipple stimulation to induce labor versus 6% with no stimulation.

Researchers have actually measured oxytocin levels in saliva before and after nipple stimulation to induce labor and demonstrated that oxytocin levels rise after the stimulation (Takahata et al. 2018). So, there is evidence that nipple stimulation supports the birthing person's own oxytocin levels. However, we do not yet have research evidence that nipple stimulation or early suckling during the third stage of labor leads to fewer cases of blood loss >1,000 mL.

Evidence on Best Practices to Use With Active Management in the Third Stage of Labor

Which Is the Better Route to Use for Pitocin® in the Third Stage of Labor: Intramuscular (IM) or Intravenous (IV)?

There is disagreement between professional organizations about the best route of giving Pitocin ® in the third stage of labor. Some recommend injection into a muscle (intramuscular or IM administration) as the preferred route (e.g., the Society of Obstetricians and Gynecologists of Canada, 2018) and others recommend both IM and injection into a vein (intravenous or IV administration) equally (e.g., the World Health Organization, 2018)

A 2018 Cochrane review examined the evidence on IM versus IV Pitocin ® for active management in the third stage of labor. They combined three randomized trials from 2014, 2015, and 2016 with over 1,300 participants assigned to IM versus IV Pitocin ® (Oladapo et al. 2018). The studies were carried out in hospital settings in Turkey (two studies) and Thailand (one study) and included pregnant people with single, term pregnancies. None of the studies were blinded. They did not find any differences between the IV and IM routes of administration, but the quality of the evidence was considered " low or very low. "

Similarly, the Cochrane meta-analysis by Salati et al. (2019), that we discussed earlier compared the IM route (four trials) to the IV route (five trials) and did not find any differences between groups. All of those trials took place between 1974 and 2010.

So, we don't yet have evidence from Cochrane meta-analyses that one route is preferable to the other route. However, three randomized trials have taken place in the last couple of years and ALL of them have found benefits to giving by Pitocin ® by IV instead of IM.

The third trial from Egypt was not blinded, but it did have several strengths (Charles et al. 2019). With nearly 5,000 participants, it was the largest of the three trials, and it excluded birthing people who received any synthetic oxytocin before the birth (such as to start or speed up labor). It also compared the IM route with two different ways of giving synthetic oxytocin-slowly as an IV infusion or quickly as an IV bolus. Like the other trials, this one also measured blood loss instead of estimating it.

This trial had three groups: The first group, assigned to the IM route, received 10 IU of synthetic oxytocin injected in the thigh. For the second group, which received an IV infusion, the synthetic oxytocin was mixed in 500 mL of fluid and given through gravity infusion with the roller clamp fully open, using an 18-gauge needle. The average time to complete the infusion was 28 minutes. The third group received an IV bolus; the bolus was pushed directly into the IV port over about one minute.

In this trial, average total blood loss was significantly less in both IV groups compared to the IM injection group. The risk of having blood loss ≥500 mL was less after IV infusion (0.8%) than after IM injection (1.5%). There was a trend toward lower risk of blood loss ≥500 mL after IV bolus (1.0%) compared to IM injection, though this finding was not statistically significant. There were no serious side effects (intensive care unit admission, shock, or death) in any of the groups.

Durocher et al. (2019) combined the data from these three trials in a meta-analysis and found that the IV routes, compared to the IM route, was linked to a significantly lower rate of PPH ≥1,000 mL (1.2% with IV versus 1.6% with IM).

In summary, the results from these three trials suggest that giving Pitocin ® either as an IV bolus pushed over one minute or as an IV infusion completed in around 30 minutes may help to reduce blood loss after birth better than IM injection among people receiving active management of the third stage of labor. However, there are other factors to consider in deciding which route to use, such as birth setting, provider skill levels, available resources, and birthing people's preferences (Durocher et al. 2019). If an IV line is already in place, then giving Pitocin ® by the IV route might make the most sense, but the IM route may be preferable if there is no IV line.

When Is the Best Time to Give Pitocin® in the Third Stage of Labor?

There are different options for timing that providers can use when giving Pitocin ® in the third stage of labor. For example, it can be given with the birth of the baby's front shoulder, immediately after the baby is born but before the cord is clamped, right after the cord is clamped, or immediately after the placenta is birthed.

The researchers did not find any benefits from giving Pitocin® before versus after birthing the placenta. There was no difference in blood loss >500 mL or >1,000 mL, retained placenta, length of the third stage of labor, changes in hemoglobin, blood transfusion, the use of additional uterotonic drugs, or the rate of low blood pressure.

There is surprisingly little research on the timing of Pitocin ® in the third stage of labor. We found one randomized trial from Turkey that was too recent to be included in the Cochrane meta-analysis (Oguz Orhan et al. 2014). This trial randomly assigned pregnant people with a single baby at term to one of four groups: IV Pitocin ® with the birth of the baby's front shoulder, IV Pitocin ® immediately after the baby was born, IM Pitocin ® with the birth of the baby's front shoulder, or IM Pitocin ® immediately after the baby was born. There were 150 people in each group.

There were no differences between groups in blood loss after birth (which was measured) or the use of additional uterotonic drugs. The people assigned to IV Pitocin ® with the birth of the baby's front shoulder had the shortest third stage of labor on average compared to the other groups and they had the least reduction in hemoglobin and hematocrit levels (indicating anemia) after birth.

However, the authors think these effects are "clinically insignificant" and they say that they did not find evidence that the route or timing of Pitocin ® impacts blood loss.

A 2013 Cochrane review and meta-analysis looked specifically at the timing of umbilical cord clamping and found that waiting to give Pitocin ® until after delayed cord clamping does not increase the risk of PPH (McDonald et al. 2013). It included 15 randomized trials with nearly 4,000 mother-baby pairs assigned to early cord clamping, defined as clamping within 60 seconds of the birth, or delayed cord clamping, defined as clamping anywhere from after one minute of the birth to when the cord stopped pulsating.

They concluded that delayed cord clamping offers significant advantages to the baby, such as higher birth weight, increased hemoglobin levels at birth, and increased iron stores in the first several months of life, with no additional risk of PPH or retained placenta for the birthing person. The overall rates of jaundice were not different between the groups. Fewer babies assigned to early clamping received light therapy for jaundice (2.7% versus 4.4%); however, the data that found this association came from an unpublished dissertation study that didn't have objective measurement of jaundice. A different meta-analysis published in the Journal of the American Medical Association (JAMA) did not include this one questionable study, and they did not find any relationship between jaundice and delayed cord clamping (Hutton & Hassan, 2007).

The Cochrane authors concluded that the potential benefits of delayed cord clamping outweigh the potential risks.

So, there is currently no evidence showing that the timing of routinely giving Pitocin® in the third stage of labor influences the rate of PPH. Waiting to give Pitocin ® until after delayed cord clamping has not been found to increase the risk of PPH.

Note in this photo above, the cord is white, limp, and not pulsating.

What Is the Evidence on Using Controlled Cord Traction With Active Management?
As we've discussed, the traditional active management approach involves giving the birthing person a uterotonic to help the uterus contract, clamping the baby's cord early, and pulling on the cord while applying counter pressure to help pull out the placenta, called controlled cord traction (CCT). It is thought that CCT helps to shorten the length of the third stage of labor and reduce blood loss.

There is a concern that giving a uterotonic drug might cause strong contractions and lead to a retained placenta if the placenta is not pulled out quickly with CCT.

A Cochrane review of three randomized trials evaluated the effects of CCT on the third stage (Hofmeyr et al. 2015). Blinding was not possible in these studies, but measuring blood loss instead of relying on subjective estimates helped to minimize bias. They considered the evidence to be high quality.

We're going to focus on the participants who were assigned to CCT or no CCT after receiving routine synthetic oxytocin (excluding those who received routine ergometrine as their uterotonic drug).

Out of 23,000 participants, there was no difference in PPH (≥500 mL), severe PPH (≥1000 mL), blood transfusion, or maternal death with or without controlled cord traction. There was a reduction in manual removal of the placenta with CCT when participants receiving ergometrine were included but not when the analysis restricted to people receiving synthetic oxytocin.

Controlled cord traction reduced blood loss by about 8 mL, which is not clinically significant, and reduced the length of the third stage by a minute or so. Fewer additional ("rescue") uterotonics were used with CCT.

The authors conclude that "women who prefer a less interventional approach to management of the third stage of labor can be reassured that when a uterotonic agent is used, routine use of CCT can be omitted from the 'active management' package without a significant increase in risk of severe postpartum haemorrhage." However, CCT may decrease the risk of manual removal of the placenta when ergometrine is used and when a strict 30-minute time limit is imposed on the third stage.

There is no research on the benefits and risks of CCT when a uterotonic drug is not used.

It's important to mention that CCT requires skill for it to be performed appropriately, since it can result in serious complications when done incorrectly (Hofmeyr et al. 2015). If traction is applied before the uterus has contracted enough, and without applying effective counter pressure to the uterus, the uterus can be pulled inside out, called uterine inversion. Cord avulsion (cord "snapping" or cord rupture) is another potential complication that occurs in about 3% of births with CCT (Berghella, 2007). Lastly, as we mentioned, there is the potential for shreds of tissue to be left behind in the uterine cavity with CCT that could increase the risk of late bleeding.

Are There Benefits to Uterine Massage in the Third Stage of Labor?

Uterine massage involves placing a hand on the birthing person's lower abdomen and stimulating the uterus to contract by rubbing and squeezing. (Massage is really a misnomer, since the forceful rubbing can be quite painful!)

A Cochrane review included two randomized trials with people who were randomly assigned to receive uterine massage or no massage after birthing the placenta (Hofmeyr et al. 2013).

The first trial included 200 people who were randomly assigned to uterine massage or no uterine massage after active management with routine synthetic oxytocin. Uterine massage was done every 10 minutes for one hour. There was no difference in blood loss >500 mL, but the average blood loss was about 40 mL less in the uterine massage group at 30 minutes and 80 mL less at 60 minutes. The use of additional uterotonics to treat heavy bleeding was less in the uterine massage group. No one experienced a retained placenta in either group.

A second and much larger trial assigned 2,000 birthing people to receive synthetic oxytocin, uterine massage or both. The group that received uterine massage alone experienced the most cases of bleeding >500 mL in 30 minutes. When synthetic oxytocin was used, they found no additional benefit from uterine massage.

We found one large randomized trial that came out after the Cochrane review (Chen et al. 2013). Here they randomly assigned 1,170 people to 10 units of synthetic oxytocin intramuscularly immediately after the birth of the baby's shoulder plus 30 minutes of continuous uterine massage and 1,170 people to intramuscular synthetic oxytocin alone. The uterine massage in addition to synthetic oxytocin did not reduce blood loss compared to synthetic oxytocin alone.

In the uterine massage group, 378 (32.3%) people reported pain when receiving uterine massage and 16 (1.4%) people asked to stop the massage because of pain.

The Cochrane authors expressed a need for more research on the effectiveness of uterine massage versus no uterine massage with expectant management, since all of this research is on active management.

We've heard care providers say that they give gentle massage (without any real force) with expectant management to help the uterus shrink after birth. Either they give the gentle massage or they instruct the birthing person in how to massage their own uterus. However, we don't have evidence yet from randomized trials to support using uterine massage with expectant management.

As far as active management, the largest study on this topic found no benefits to uterine massage when synthetic oxytocin was used. Furthermore, many women have contacted us at Evidence Based Birth ® to state that the experience is extremely painful, and some have traumatic memories of this experience.

Uterine massage is distinct from postpartum assessment of fundal tone, which is recommended to identify uterine atony (WHO, 2012). To assess fundal tone, the care provider places their hand lightly on top of the uterus to feel whether or not it's contracting regularly. If it's not, they may ask the birthing person to either chestfeed/breastfeed the baby or self-perform nipple stimulation to encourage contractions by stimulating the body's own naturally produced (endogenous) oxytocin.

Are There Any Trainings Health Care Professionals Can Take to Improve Outcomes With PPH?

Care providers can prepare for obstetric emergencies before they occur! The American Academy of Family Physicians (AAFP) designed a comprehensive, evidence-based course called Advanced Life Support in Obstetrics (ALSO™) training to prepare maternity care providers to effectively manage potential emergencies during pregnancy and childbirth, including PPH (Personal correspondence, Ann Evensen, MD, FAAFP, May 17, 2020).

In the ALSO training, learners complete an online prep portion of the course prior to attending a one-day in-person course. The in-person training is focused on hands-on demonstration of skills as well as team building and the importance of the team in managing obstetric emergencies. The course is taught by certified ALSO faculty who are ALSO providers and have completed an in-person course on ALSO instruction. They have to maintain certain requirements for certification, and they maintain a low instructor to student ratio. Over 100,000 care providers around the world have attended this course!

A 2011 study of around 1,000 births in Tanzania compared PPH outcomes before versus after providers completed the ALSO training (Sorensen et al. 2011). After the training, severe PPH (blood loss ≥1000 mL) was significantly reduced from 9.2% to 4.3%. So, completing the ALSO course is an evidence-based way for providers to reduce PPH.

The full ALSO course is important for all providers who regularly attend births regardless of birth setting. Even if someone does not have all of the medications and other interventions available to them in a home or freestanding birth center, the course will help them understand what is available and why the intervention might be used in an emergency. In addition, some of the maneuvers/interventions for PPH as well as shoulder dystocia (when the baby's shoulder gets stuck during birth), breech birth, maternal resuscitation, and cord prolapse can be done in the community setting.

The Basic Life Support in Obstetrics (BLSO™) course is adapted from ALSO. It's a good option for those who do not regularly attend births but want to be proficient in emergency assessment and management during childbirth. BLSO is designed to train first responders and emergency personnel and it's an excellent introduction for students. We strongly encourage health care professionals and students to take advantage of ALSO or BLSO trainings!

Recent Practice Guidelines

The World Health Organization (WHO) recommends using Pitocin ® (10 IU, IM/IV) with all births during the third stage of labor to prevent PPH (WHO, 2018). In settings where synthetic oxytocin is not available, they recommend using another effective uterotonic drug. The WHO considers the use of a uterotonic drug (i.e., Pitocin ®) to be the most important part of the active management package (WHO, 2019). They say that controlled cord traction in combination with Pitocin ® may add a small benefit when performed by a skilled attendant, but uterine massage probably adds no benefit to preventing PPH. The WHO recommends that the umbilical cord not be clamped any earlier than is necessary for controlled cord traction, which they say is normally around three minutes.

The International Confederation of Midwives describes the third stage of labor as a "time of adjustment" when the birthing person is adjusting to the changes that follow birth and the baby is adjusting to life outside of the uterus (2008, Revised 2017). It is their position that competency in both active and expectant management of the third stage of labor is "a basic midwifery competency." The role of the midwife is to provide all of the necessary information and then support the birthing person's informed decision about which interventions they desire for their "placental birth."

The American College of Obstetricians and Gynecologists (2017, Reaffirmed 2019) recommends that all birth facilities should have guidelines in place for giving routine Pitocin ® after birth. They say that Pitocin ® can be given by IV infusion (bolus dose of 10 units), or IM injection (10 IU). ACOG states that "delaying oxytocin until after delayed umbilical cord clamping has not been found to increase risk of hemorrhage."

The California Maternal Quality Care Collaborative (CMQCC) developed the OB Hemorrhage Toolkit V 2.0 in 2015 (CMQCC, OB Hem Task Force, 2015). They support using active management for all birthing people. However, they emphasize synthetic oxytocin as the main component of active management and clearly state that active management should not interfere with delayed cord clamping. Similarly, active management should not delay skin-to-skin care.

The Society of Obstetricians and Gynecologists of Canada (SOGC) recommends offering active management to everyone to reduce PPH (SOGC, 2018). They specify that 10 IU of synthetic oxytocin should be given IM with low-risk vaginal births, immediately after the birth of the anterior (front) shoulder. They consider an IV infusion of synthetic oxytocin (20 to 40 IU in 1,000 mL, 150 mL per hour) to be an acceptable alternative. An IV bolus of 5 to 10 IU (given over 1 to 2 minutes) can also be used after vaginal births.

The U.K.'s National Institute for Health and Care Excellence (NICE) defines active management as the routine use of uterotonic drugs, delayed clamping and cutting of the cord, and controlled cord traction after signs that the placenta has separated. They define 'physiologic management' as no routine use of uterotonic drugs, no clamping of the cord until pulsation has stopped, and birthing the placenta by the mother's pushing efforts alone. They recommend active management for everyone, but say that a woman at low risk of PPH who chooses physiologic management should be supported in her choice. They recommend 10 IU of synthetic oxytocin by IM injection with the birth of the baby's front shoulder or immediately after the birth of the baby and before the cord is clamped and cut.

The Association of Ontario Midwives published an excellent, very comprehensive guideline on PPH in 2016 (Association of Ontario Midwives, 2016). They recommend that midwives should identify risk factors for PPH during pregnancy and birth and discuss these risk factors and options for management of the third stage of labor in an informed choice discussion.

If the birthing person chooses active management, midwives should use synthetic oxytocin; wait until pulsation stops to clamp and cut the cord; and use controlled cord traction to birth the placenta. Uterine massage is not recommended.

If the birthing person chooses expectant management, midwives should watch for signs that the placenta has separated and monitor blood loss; wait until pulsation stops or the placenta is birthed to clamp and cut the cord; wait for the placenta to be born with maternal effort or gravity (skilled midwives may offer controlled cord traction); and encourage immediate skin-to-skin contact with the infant, early breastfeeding/chestfeeding, and other measures that may encourage the release of the mother's natural oxytocin. Uterine massage is not recommended.

Conclusions

Parents today can choose from three different types of management of the third stage of labor:

Expectant management involves supporting the birthing person's natural release of oxytocin, waiting to clamp the cord until it has stopped pulsating, and using gravity or the mother's own pushing efforts to birth the placenta.

Traditional active management is the routine use of a uterotonic medication, early cord clamping, controlled cord traction (pulling on the cord) to birth the placenta, and sometimes uterine massage. Randomized trials comparing active management with and without early cord clamping, controlled cord traction, and uterine massage have shown that the uterotonic medication is the most important part of the active management package.

Mixed management combines methods from the expectant and active management approaches; for example, someone may choose physiologic (delayed) cord clamping and a uterotonic drug with no cord traction.

Early cord clamping has traditionally been part of the active management package, but professional organizations around the world now discourage early cord clamping and no longer consider it part of an effective active management approach.

Early cord clamping has been shown by randomized trials to cause harm to infants by lowering their iron stores and increasing the risk of iron-deficiency anemia.

Parents can ask their care provider to leave the cord unclamped until it has stopped pulsating (usually takes at least 5 minutes), regardless of whether or not they use Pitocin® in the third stage of labor. Waiting to give Pitocin® until after delayed cord clamping does not increase the risk of PPH. During delayed cord clamping, the baby should be skin-to-skin on the birthing person's abdomen or chest.

Rates of postpartum hemorrhage have been on the rise around the world.

Prior definitions of PPH included anyone who suffered a blood loss of 500 mL or more after a vaginal birth. A loss of 500 mL is equivalent to a routine blood donation and may be considered physiologic blood loss for a healthy adult giving birth.

The U.S. reVITALize definition for early PPH includes (1) blood loss of ≥1000 mL or (2) any amount of blood loss that is accompanied by signs/symptoms of low blood volume within 24 hours after giving birth.

PPH causes more than a quarter of maternal deaths globally, and in the U.S., it is thought to cause about 1 in 10 pregnancy-related deaths. A large study in the U.S. found that the risk of death from PPH was five times higher for Black birthing people compared to White birthing people-highlighting the massive racial injustices in our health care system.

Care providers can prepare for obstetric emergencies before they occur: The American Academy of Family Physicians (AAFP) designed a comprehensive, evidence-based course called Advanced Life Support in Obstetrics (ALSO™) that can help lower the risk of blood loss ≥1,000 mL. We strongly encourage care providers to take advantage of ALSO or BLSO trainings!

A meta-analysis of randomized trials shows that there are both potential benefits and potential harms to active management and expectant management.

Compared to expectant management, active management reduced the average amount of blood loss at birth (by around 80 mL); the risk of blood loss greater than 500 mL (5% versus 15%); the risk of blood loss greater than 1,000 mL (0.9% versus 2.4%); the risk of blood transfusion (1% versus 3%); and the risk of anemia after birth (4% versus 7%) in a group that included both people at higher risk for PPH and those at lower risk for PPH. These benefits are likely due to the uterotonic alone (not early cord clamping or controlled cord traction). There were also downsides to active management: it increased the need for pain medication because of afterpains (5% versus 2%) and increases the risk of returning to the hospital for excess bleeding later on (3% versus 1%).

At this time, there is no evidence that active management reduces the risk of blood loss ≥1,000 mL when focusing only on people considered to be at low risk of PPH.

The evidence we have from randomized trials comes from settings where the care providers are more familiar with active than expectant management, and where interventions, including the use of synthetic oxytocin to start and speed up labor, are extremely common. Observational studies have not shown an increase in blood loss among pregnant people at low risk for PPH who experience expectant management with a skilled provider after a physiologic labor and birth.

Researchers have written about best practices for both active management and expectant management.

Best practices for active management include:

Use synthetic oxytocin (Pitocin®) as the uterotonic.

Wait until pulsation stops to clamp and cut the cord. Giving Pitocin® after delayed cord clamping has not been found to increase the risk of PPH. There is currently no evidence showing that the timing of routinely giving Pitocin® in the third stage of labor influences the rate of PPH.

Consider giving Pitocin® either as an IV bolus pushed over one minute or as an IV infusion completed in around 30 minutes because recent studies show it may help to reduce blood loss better than IM injection.

Controlled cord traction is optional for skilled providers; any benefits are minor, there is a potential for complications when performed incorrectly, and omitting it has not been shown to increase the risk of severe blood loss.

Uterine massage is not recommended, but postpartum assessment of fundal tone is recommended to identify uterine atony.

Best practices for expectant management can be better called "psychophysiological care" (Hastie and Fahy, 2009) and include:

Await signs that the placenta has separated and monitor the birthing person for excessive blood loss (assess the volume of blood loss, the speed of blood flow, and the mother's condition).

Wait until pulsation stops to clamp and cut the cord.

Support the birthing person in upright positions as they birth their placenta with pushing efforts or gravity.

Encourage immediate skin-to-skin contact with the newborn and early opportunities to breastfeed/chestfeed.

Foster a birth space that feels warm, calm, private, and safe to encourage the mother's own oxytocin release.

Uterine massage is not recommended (there is no evidence on using uterine massage without a uterotonic), but postpartum assessment of fundal tone is recommended to identify uterine atony.

Have a uterotonic drug available to use as treatment if excess bleeding occurs.

Bottom Line

Both modern active management (i.e. mixed management) and expectant management (especially "psychophysiological care") during the third stage of labor are reasonable choices. The risks and benefits of each approach should be discussed with birthing families so they can make an informed choice about their care for the third stage. Informed consent discussions should include how individual risk factors, if present, could increase risk of PPH, how unplanned interventions and complications could increase risk of PPH (and mean reevaluating active versus expectant management at that point), and the birthing person's values and preferences.

Early cord clamping is no longer recommended, and parents should be supported in their choice if they ask for the cord to remain unclamped until it has turned white and stopped pulsating.

Discussions can also include what the birth setting's ability is to provide each type of third stage care. We list some of the best practices for each approach above. You can take this information and have a discussion with your care provider about how they usually handle the third stage of labor and how the birth setting could best support your desired approach.

References:

Abedi, P., Jahanfar, S., Namvar, F., et al. (2016). Breastfeeding or nipple stimulation for reducing postpartum haemorrhage in the third stage of labour. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD010845. Click here. Free full text!

Adnan, N., Conlan-Trant, R., McCormick, C., et al. (2018). Intramuscular versus intravenous oxy- tocin to prevent postpartum haemorrhage at vaginal delivery: randomised controlled trial. BMJ, 4. 362. Click here. Free full text!

Aflaifel, N. and Weeks, A. (2012). Push, pull, squeeze, clamp: 100 years of changes in the management of the third stage of labour as described by Ten Teachers. BMJ, 345, e8270. Click here.

American College of Nurse-Midwives, Midwives Alliance of North America, National Association of Certified Professional Midwives (2012). Supporting healthy and normal physiologic child- birth: a consensus statement by the American College of Nurse-Midwives, Midwives Alliance of North America, and the National Association of Certified Professional Midwives. J Midwifery Womens Health, 57(5), 529-532. Click here.

American College of Obstetricians and Gynecologists (2017, Reaffirmed 2019). Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol, 130, e168. Click here.

Anger, H., Durocher, J., Dabash, R., et al. (2019). How well do postpartum blood loss and common definitions of postpartum hemorrhage correlate with postpartum anemia and fall in hemoglobin? PLoS One, 14, e0221216. Click here. Free full text!

Association of Ontario Midwives (2016). AOM PPH CPG Work Group. Postpartum Hemorrhage. Accessed online November 13, 2019.

Begley, C. M., Guilliland, K., Dixon, L., et al. (2012). Irish and New Zealand midwives' expertise in expectant management of the third stage of kabour: the 'MEET' study. Midwifery, 28(6), 733-739. Click here.

Begley, C. M., Gyte, G. M. L., Devane, D., et al. (2019). Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD007412. Click here.

Berghella, V. (2007). Obstetric Evidence Based Guidelines. Informa UK Ltd. Click here.

Berghella, V., Lockwood, C. J., and Barss, V. (2019). UpToDate® Management of the third stage of labor: Drug therapy to minimize hemorrhage.

Buckley, S. J. (2020). Leaving Well Alone: A Natural Approach to the Third Stage of labour. Accessed online February 4, 2020.

California Maternal Quality Care Collaborative (CMQQC), OB Hem Task Force (2015). OB Hem Active Management of the Third Stage Labor. Accessed online March 27, 2020.

Chamberlain G. (2006). British maternal mortality in the 19th and early 20th centuries. Journal of the Royal Society of Medicine, 99(11), 559-563. Click here. Free full text!

Charles, D., Anger, H., Dabash, R., et al. (2018). Intramuscular injection, intravenous infusion, and intravenous bolus of oxytocin in the third stage of labor for prevention of postpartum hemorrhage: a three-arm randomized control trial. BMC Pregnancy Childbirth, 19, 38. Click here. Free full text!

Chen, M., Chang, Q., Duan, T., et al. (2013). Uterine massage to reduce blood loss after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 122(2 Pt 1), 290-295. Click here.

Cheyney, M., Bovbjerg, M., Everson, C., et al. (2014). "Outcomes of care for 16,924 planned home births in the United States: the Midwives Alliance of North America Statistics Project, 2004 to 2009." J Midwifery Womens Health, 59(1), 17-27. Click here.

Combs, C. A. and Laros, R. K. Jr. (1991). Prolonged third stage of labor: morbidity and risk factors. Obstetrics and Gynecology, 77(6), 863-867.

Dashtinejad, E., Abedi, P. and Afshari P. (2018). Comparison of the effect of breast pump stimulation and oxytocin administration on the length of the third stage of labor, postpartum hemorrhage, and anemia: a randomized controlled trial. BMC Pregnancy Childbirth, 18(1), 293. Click here. Free full text!

Declercq, E. R., Sakala, C., Corry, M. P., et al. (2013). Listening to MothersSM III: Pregnancy and Birth. New York: Childbirth Connection, May 2013. Click here. Free full text!

Dencker, A., Smith, V., McCann, C., et al. (2017). Midwife-led maternity care in Ireland - a retrospective cohort study. BMC Pregnancy Childbirth, 17(1), 101. Click here. Free full text!

Diaz, V., Abalos, E. and Carroli, G. (2018). Methods for blood loss estimation after vaginal birth.

Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD010980. Click here. Free full text!

Dixon, L., Tracy, S. K., Guililand, K. (2013). Outcomes of physiological and active third stage labour care amongst women in New Zealand. Midwifery, 29(1), 67-74. Click here.

du Vigneaud, V., Ressler, C. and Trippett, S. (1953). The sequence of amino acids in oxytocin, with a proposal for the structure of oxytocin. J Biol Chem., 205(2), 949-57.

Durocher, J., Dzuba, I. G., Carroli, G., et al. (2019). Does route matter? Impact of route of oxytocin administration on postpartum bleeding: A double-blind, randomized controlled trial. PLoS ONE 14(10): e0222981. Click here. Free full text!

Erickson, E. N., Lee, C. S., and Emeis, C. L. (2017). Role of Prophylactic Oxytocin in the Third Stage of Labor: Physiologic Versus Pharmacologically Influenced Labor and Birth. J Midwifery Womens Health, 62(4), 418-424. Click here.

Evensen, A., Anderson, J. M. and Fontaine, P. (2017). Postpartum Hemorrhage: Prevention and Treatment. Am Fam Physician. 95(7), 442-449. Click here. Free full text!

Fahy, K., Hastie, C., Bisits, A., et al. (2010). Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum hemorrhage: a cohort study. Womens Birth, 23(4), 146-52. Click here.

Farrar, D., Tuffnell, D., Airey, R., et al. (2010). Care during the third stage of labour: a postal survey of UK midwives and obstetricians. BMC Pregnancy Childbirth 10 (1), 23. Click here. Free full text!

Ford, J. B., Roberts, C. L., Simpson, J. M., et al. (2007). Increased postpartum hemorrhage rates in Australia. International Journal of Gynecology & Obstetrics, 98(3), 237-243. Click here.

Fuchs, A. R. and Fuchs, F. (1984). Endocrinology of human parturition: a review. Br J Obstet Gynaecol, 91(10), 948-967. Click here.

Funai, E. F., Norwitz, E. R., Lockwood, C. J., et al. (2019). UpToDate® Management of normal labor and delivery.

Grobman, W., Lockwood, C. J. and Barss, V. A. (2019). UpToDate® Induction of labor with oxytocin.

Gyamfi-Bannerman, C., Srinivas, S. K., Wright, J. D., et al. (2018). Postpartum hemorrhage outcomes and race. Am J Obstet Gynecol. 219(2), 185.e1-185.e10. Click here.

Hancock, A. Weeks, A. D. and Lavender, D. T. (2015). Is accurate and reliable blood loss estimation the 'crucial step' in early detection of postpartum haemorrhage: an integrative review of the literature. BMC Pregnancy Childbirth, 15, 230. Click here. Free full text!

Hastie, C. and Fahy, K. M. (2009). Optimising psychophysiology in third stage of labour: theory applied to practice. Womens Birth, 22(3), 89-96. Click here.

Hofmeyr, G. J., Abdel-Aleem, H. and Abdel-Aleem, M. A. (2013). Uterine massage for preventing postpartum haemorrhage. Cochrane Database of Systematic Reviews, Issue 7. Art. No.: CD006431. Click here.

Hofmeyr, G. J., Mshweshwe, N. T. and Gülmezoglu, A. M. (2015). Controlled cord traction for the third stage of labour. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD008020. Click here. Free full text!

Homer, C. S., Leap, N., Edwards, N., et al. (2017). Midwifery continuity of carer in an area of high socio-economic disadvantage in London: A retrospective analysis of Albany Midwifery Practice outcomes using routine data (1997-2009). Midwifery, 48, 1-10. Click here. Free full text!

Hutton, E. K. and Hassan, E. S. (2007). Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials. JAMA. 297(11), 1241‐1252. Click here.

International Confederation of Midwives (2008, Revised 2017). Role of the Midwife in Physiological Third Stage Labour: ICM Position Statement. Adopted at Glasgow Council meeting, 2008 and revised at Toronto Council meeting, 2017. Due for next review 2023. Click here. Free full text!

Jangsten, E., Bergh, I., Mattson, L. A., et al. (2011). Afterpains: a comparison between active and expectant management of the third stage of labor. Birth, 38(4), 294-301. Click here.

Kavanagh, J., Kelly, A. J. and Thomas, J. (205). Breast stimulation for cervical ripening and induction of labour. Cochrane Database Syst Rev. (3), CD003392. Click here.

Kjerulff, K. H., Attanasio, L. B., Edmonds, J. K., et al. (2017). Labor induction and cesarean delivery: A prospective cohort study of first births in Pennsylvania, USA. Birth (Berkeley, Calif.), 44(3), 252-261. Click here. Free full text!

Kramer, M. S., Berg, C., Abenhaim, H., et al. (2013). Incidence, risk factors, and temporal

trends in severe postpartum hemorrhage. Am J Obstet Gynecol, 209(5), 449.e1-7. Click here.

Kramer, M. S., Dahhou, M., Vallerand, D., et al. (2011). Risk factors for postpartum hemorrhage: can we explain the recent temporal increase? J Obstet Gynaecol Can., 33(8):810-819. Click here.

Main, E. K., Cape, V., Abreo, A., et al. (2017). Reduction of severe maternal morbidity from hemorrhage using a state perinatal quality collaborative. Am J Obstet Gynecol. 216(3), 298.e1‐298.e11. Click here.

Magon, N. and Kalra, S. (2011). The orgasmic history of oxytocin: Love, lust, and labor. Indian journal of endocrinology and metabolism, 15 Suppl 3(Suppl3), S156-S161. Click here. Free full text!

Martin, J. A., Hamilton, B. E., Osterman, M. J. K., et al. (2019). Births: Final data for 2018. National Vital Statistics Reports; vol 68, no 13. Hyattsville, MD: National Center for Health Statistics. Click here. Free full text!

Mavrides, E., Allard, S., Chandraharan, E., et al. on behalf of the Royal College of Obstetricians and Gynaecologists (2016). Prevention and management of postpartum haemorrhage. BJOG, 124, e106-e149. Click here. Free full text!

McDonald, S. J., Middleton, P., Dowswell, T., et al. (2013). Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews, Issue 7. Art. No.: CD004074. Click here. Free full text!

Meisenberg, G. and Simmons, W. H. (1983). Peptides and the blood-brain barrier. Life Sciences, 32(23), 2611-2623. Click here.

National Institute for Health and Care Excellence (2019). Care in third stage of labour. Accessed online November, 13, 2019. Available at: https://pathways.nice.org.uk/pathways/intrapartum-care/care-in-third-stage-of-labour

Oberg, A. S., Hernandéz-Diaź, S., Frisell, T., et al. (2014). Genetic contribution to postpartum haemorrhage in Swedish population: cohort study of 466,686 births. BMJ, 349:g4984. Click here. Free full text!

Oguz Orhan, E., Dilbaz, B., Aksakal, S. E., et al. (2014). Prospective randomized trial of oxytocin administration for active management of the third stage of labor. International Journal of Gynecology & Obstetrics, 127(2), 175-179. Click here.

Oladapo, O. T., Okusanya, B. O., Abalos, E. (2018). Intramuscular versus intravenous prophylactic oxytocin for the third stage of labour. Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD009332. Click here. Free full text!

OpenStax, Anatomy & Physiology (2016). OpenStax CNX. Maternal Changes During Pregnancy, Labor, And Birth. Accessed online March 27, 2020.

Quintana, D. S., Smerud, K. T, Andreassen, O. A., et al. (2018). Evidence for intranasal oxytocin delivery to the brain: recent advances and future perspectives. Therapeutic Delivery, Vol. 9, No. 7. Click here. Free full text!

Razvi, K., Chua, S., Arulkumaran, S., et al. (1996). A Comparison Between Visual Estimation and Laboratory Detennination of Blood Loss During the Third Stage of Labour. Aust N Z J Obstet Gynaecol, 36, 152-4. Click here.

Reed, R., Gabriel, L. and Kearney, L. (2019). Birthing the placenta: women's decisions and experiences. BMC Pregnancy Childbirth. 19(1), 140. Click here. Free full text!

Salati, J. A., Leathersich, S. J., Williams, M. J., et al. (2019). Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD001808. Click here.

Schorn, M.N., Dietrich, M.S., Donaghey, B., et al. (2017). US Physician and midwife adherence to active management of the third stage of labor international recommendations. J. Midwifery Women's Health 62 (1), 58-67. Click here.

Sheiner, E., Sarid, L., Levy, A., et al. (2005). Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. Journal of Maternal-Fetal & Neonatal Medicine, 18(3), 149-54. Click here.

Society of Obstetricians and Gynecologists of Canada (2018). No. 235-Active Management of the Third Stage of Labour: Prevention and Treatment of Postpartum Hemorrhage. J Obstet Gynaecol Can, 40(12), e841-e855. Click here.

Soltani, H., Hutchon, D. R. and Poulose, T. A. (2010). Timing of prophylactic uterotonics for the third stage of labour after vaginal birth. Cochrane Database of Systematic Reviews, Issue 8. Art. No.: CD006173. Click here.

Sorensen, B., Rasch, V., Massawe, S., et al. (2011). Advanced Life Support in Obstetrics (ALSO) and post-partum hemorrhage: a prospective intervention study in Tanzania. Acta Obstet Gynecol Scand. 90, 609-614. Click here.

Takahata, K., Horiuchi, S., Tadokoro, Y., et al. (2018). Effects of breast stimulation for spontaneous onset of labor on salivary oxytocin levels in low-risk pregnant women: A feasibility study. PLoS One, 13(2), e0192757. Click here. Free full text!

Uvnäs-Moberg, K., Ekström-Bergström, A., Berg, M., et al. (2019). Maternal plasma levels of oxytocin during physiological childbirth - a systematic review with implications for uterine contractions and central actions of oxytocin. BMC pregnancy and childbirth, 19(1), 285. Click here. Free full text!

van Stralen, G., von Schmidt Auf Altenstadt, J. F., Bloemenkamp, K W., et al. (2016). Increasing incidence of postpartum hemorrhage: the Dutch piece of the puzzle. Acta Obstet Gynecol Scand., 95(10), 1104-10. Click here.

Vogel, J. P., Williams, M., Gallos, I., et al. (2019). WHO recommendations on uterotonics for postpartum haemorrhage prevention: what works, and which one?. BMJ Glob Health. 4(2), e001466. Click here. Free full text!

Weeks, A. D. (2008). The retained placenta. Best Practice & Research Clinical Obstetrics & Gynaecology, 22(6), 1103-1117. Click here.

Weeks, A., Berghella, V. and Barss, V. A. (2019). UpToDate® Retained placenta after vaginal birth.

World Health Organization (2012). WHO recommendations for the prevention and treatment of postpartum haemorrhage. Accessed online February 6, 2020.

World Health Organization (2018). Uterotonics for the prevention of postpartum haemorrhage. Accessed online October 30, 2019.

World Health Organization (2019). Optimal timing of cord clamping for the prevention of iron deficiency anaemia in infants. Accessed online November 13, 2019.

Resources:

Advanced Life Support in Obstetrics (ALSO) training was designed by the American Academy of Family Physicians (AAFP) to prepare maternity care providers to effectively manage potential emergencies during pregnancy and childbirth, including PPH. You can find information about how to hold a course, attend a course, or instruct a course on the AAFP website here!

The California Maternal Quality Care Collaborative (CMQCC) developed the OB Hemorrhage Toolkit V 2.0 in 2015 (CMQCC, OB Hem Task Force, 2015). You can download the toolkit here!

Sarah Buckley's 2015 report on the Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care is available at: ChildbirthConnection.org/HormonalPhysiology.

Cochrane authors independently assess the quality of the evidence in their reviews using the GRADE approach. We indicated whether the evidence was considered high, moderate, low, or very low quality for many of the outcomes discussed in this article. You can find all of the details on the GRADE approach to assessing the quality of evidence in the GRADE Handbook here.

Acknowledgements

We are grateful to our reviewers for this article- Margaret Buxton, CNM, DNP, Director of Clinical Operations, Baby & Co; Audrey Lyndon, PhD, RNC, FAAN, Professor of Nursing and Medicine, Assistant Dean for Clinical Research at NYU Rory Meyers College of Nursing; Debbie Newton, APRN, CNM, MSN; Paula Richards, MSN, RNC-OB, C-EFM; Nathan Riley, Obstetrician, Palliative Medicine; and Shannon J. Voogt, MD, Board-Certified in Family Medicine.

We also wish to thank Cristen Pascucci for her medical editing assistance.

Cover Photo Credit: Katie McKinney Photography

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Evidence on: Pitocin® During the Third Stage of Labor - Evidence Based Birth®

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We ask: What are the potential benefits and risks of Pitocin® during the third stage? What is the evidence for expectant versus active or mixed management?

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Normally I'm on the other side of the microphone, interviewing others for the Better Birth podcast, but I have dipped my toes in to the other side a few times! Check out my episodes on other podcasts,

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The second stage of labour is the expulsive phase, and it's the stage so often represented in TV and film. Time and time again we're shown guided pushing as the norm. Red faced and sweaty, the person giving birth is shouted at by a midwife or healthcare professional telling them when to push.

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If this is your first pregnancy or your first time on an antenatal class you may hear folk talk about The Apgar Score, and wonder what the hell that is. Well let me enlighten you. The Apgar Score is a test given to newborns soon after birth. It is a way for doctors and midwives to check a baby’s hea…

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A nuchal cord happens when your baby’s umbilical cord becomes wrapped around their neck in the womb. Nuchal cords are quite common, and while they often do not cause any health problems, in rare cases, serious complications can occur.

Here is what you need to know about nuchal cords, their potential risks, and how doctors treat them.

What Is a Nuchal Cord?

The umbilical cord is responsible for delivering the oxygen and nutrients your baby needs to grow, as well as for carrying away waste. It’s a flexible tube that contains two arteries and one vein and is coated in a substance called Wharton’s jelly, which helps to protect the blood vessels inside.

If your baby’s umbilical cord gets wrapped around the baby’s neck one or more times, it is called a nuchal cord. The loops can be either loose or tight. Nuchal cords are grouped into types A and B.

Type A nuchal cords (also called unlocked cords) are free-moving and may come undone naturally. Type B nuchal cords (or locked chords) are wrapped in a way that does not allow them to come undone naturally, except for very rare cases.

What Causes a Nuchal Cord?

The fetal movements your baby makes before they are born is the most common cause of nuchal cords. An extra amount of amniotic fluid, allowing your baby to move around more freely, as well as a longer than average umbilical cord, might also cause your baby to have a nuchal cord.

Are There Risks of a Nuchal Cord?

Nuchal cords happen randomly and are very common. Research suggests they happen in more than one in four births. Type B nuchal cords are less common, with about 2% to 8% of babies born with one.

Research has shown that the longer your baby stays in your womb, the greater chance there might be for them to be born with their umbilical cord wrapped around their neck. Nuchal cords have been reported in 6% of babies at 20 weeks gestation, but that number increased to 29% at 42 weeks. Male babies are also more commonly born with nuchal cords than female babies.

Race and maternal age do not affect the chances of a baby having a nuchal cord. Labor also does not typically play a role. If your baby doesn’t have a nuchal cord before you go into labor, they are very unlikely to have one at birth.

Are There Complications of a Nuchal Cord?

While most nuchal cords do not cause babies any harm, some potential complications include:

Umbilical cord knots

Developmental delays

Decreased amounts of amniotic fluid

Decreased fetal movement

Longer gestation periodS

Intrauterine growth restriction (IUGR)

Anemia

Low levels of circulating blood (hypovolemia)

High levels of blood acid (metabolic acidosis)

Stillbirth

Sometimes the nuchal cord can wrap tightly around your baby’s neck and cause complications. This can lead to a condition called tCAN (tight cord around neck) syndrome. Symptoms of tCAN syndrome are similar to strangulation and include blood spots (petechiae) on the neck, face, and in the eyes; skin abrasions on the neck where the cord was wrapped; and dusky, purple colored skin on the face.

How Is a Nuchal Cord Diagnosed?

Nuchal cords can sometimes be seen during prenatal ultrasounds, but they are often first found at birth. Nuchal cords happen often, so it’s common for doctors to routinely check for one during delivery.

Is There Treatment for a Nuchal Cord?

There are currently no nuchal cord treatment options before your baby is born.  If your baby's nuchal cord is diagnosed before birth, you will likely have extra monitoring during labor to make sure your baby's heart rate is normal.

During birth, nuchal cords are normally loose enough for your doctor to loop the cord back around the baby’s head and free their neck. If the cord is too tight to slip over your baby’s head, it might be clamped and cut before your baby is completely delivered to prevent it from tearing away from the placenta.

If your baby’s heart rate declines during labor because of a nuchal cord, your doctor might have you change positions to relieve any extra pressure put on the umbilical cord, and give you extra fluids or oxygen. If your baby’s heart rate doesn’t improve, you may be given medication to slow down your contractions or have a cesar ean section.

Should I Worry If My Baby Has a Nuchal Cord?

Nuchal cords are very common and rarely cause any lasting complications or harm to your baby. Babies born with nuchal cords typically don’t have any increased risk of low Apgar scores, growth and developmental problems, or stillbirth. Be sure to talk with your doctor if you have any questions or concerns about nuchal cords during pregnancy or delivery.

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Learn about nuchal cords and the possible causes, risks, complications, and management options.

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System Pressures

There are many pressures in hospitals that limit caregivers from truly supporting birthing people. Too few nurses and increased charting duties limit nurses' ability to perform intermittent auscultation or to provide hands-on support for different birthing positions-especially for patients with epidurals who require extra assistance.

If you have an epidural, you may need two assistants to help you move into certain positions, which is not possible if a hospital is short-staffed on nurses, or if the nurse is supposed to be charting on the computer every five to ten minutes for medical, legal, and insurance reasons.

If hospitals were willing to invest in more hands-on care to support birthing families, we would likely see more auscultation (instead of continuous EFM) and more staff support for position changes during labor, pushing, and birth.

Many birthing people find that one of the benefits of hiring an independent doula is that the doula can team up with other family members (such as the partner) to help you push and give birth in upright positions (whether you have an epidural or not). To read the evidence on doulas, visit https://evidencebasedbirth.com/doulas

Symbolic Importance of the Hospital Bed

Hospitals often invest tens of thousands of dollars in specialized birthing beds that can be broken down to support a range of positions (from lithotomy to hands and knees to squatting). The hospital bed takes a central location and importance in the typical hospital birthing room (almost throne-like in its placement), and each bed can cost anywhere between $4,000 and $10,000 USD.

The hospital bed itself is a potent symbol of the rite of passage of having a technologically driven birth. Anthropologist Robbie Davis-Floyd, PhD, writes that "Rituals transmit their meaning through symbols. A symbol is an object, idea, or action that is loaded with cultural meaning. Instead of being analyzed intellectually, a symbol's message will be felt through the body and the emotions... Routine obstetric procedures are highly symbolic." (Davis-Floyd, p. 49).

When a birthing person puts on a hospital gown and gets into the hospital bed, this symbol conveys that they are sick and need the technology and skills of the hospital staff. Then, when the hospital bed is combined with the lithotomy position (in which the birthing person is positioned with their legs up in the air and genitals exposed for everyone to see, with the practitioner standing over them), this can be seen as a symbol of powerlessness (for the birthing person) and status/authority (for the practitioner).

The significant financial, ritual, and symbolic meaning of hospital beds may help explain why hospital staff are so insistent that deliveries (whether upright or lying down) should always take place in bed.

In contrast, births that take place at home and in freestanding birth centers provide access to a variety of props, furniture, and tools. These environments encourage upright birthing, with the purpose of facilitating physiological birth and empowering the birthing person.

In the first randomized controlled trial of its kind (still ongoing at the time we updated this article) researchers in Germany are studying changes to hospital birthing rooms that encourage upright positions and enhance relaxation and comfort (Ayerle et al. 2018). In the "intervention group," birthing people have access to a room that includes:

Bed that is absent or hidden from sight

Mattress and foam mat on the floor

Bean bag or easy chair

Foam element shaped like a birthing stool

Snack bar with table and chairs

Posters showing upright positions

Monitor showing natural sounds/music

Sign on the door requesting privacy

In the "control" group, the delivery bed has a central place in the room and is accessible from three sides. A birthing stool, birth ball, and length of fabric suspended from the ceiling (to use for support while standing/squatting) remain available as is usual in some hospitals in Germany.

The results from this study, known as the "BE-UP" trial, have not yet been published. The researchers plan to examine the effects of the birthing rooms on Cesarean rates, episiotomy rates, perineal tears, epidural use, newborn health, and maternal feelings of self-determination.

A similar study, known as the "Room4Birth" trial, is also taking place in Sweden (Berg et al. 2019).

So, what's the actual research evidence on birthing positions?

Because most researchers study birthing positions only in people without epidurals, or only in those with epidurals, we will divide the research up based on epidural use.

Without epidurals, which birthing positions are best supported by evidence?

In a systematic review and meta-analysis published by Zang et al. (2020), researchers combined 12 randomized, controlled trials with 4,314 participants who were randomly assigned to upright vs. recumbent birth.

The researchers excluded any studies that used the lithotomy position because of its known harms and increased risks. They stated, "these horizontal positions can have serious negative effects on maternal health and are not recommended by many international organizations." As a result, this review is smaller than the Cochrane review and meta-analysis by Gupta et al. (2017), which included the lithotomy position and thus had a larger number of participants.

The Zang et al. team followed the PRISMA guidelines for reviews ( https://prisma-statement.org/ ), and they included studies that had participants with low-risk pregnancies at 37-42 weeks. Participants had to be pregnant with a single baby in spontaneous labor, and they could not have an epidural.

The researchers compared upright versus recumbent positions.

They defined "upright" as walking, standing, leaning, using a birth chair, semi-sitting, squatting, and kneeling.

However, none of the included studies used semi-sitting as an upright position.

Upright birthing positions were used only in the passive pushing phase in 4 studies, only in the active pushing phase in 3 studies, and in the entire second stage in 7 studies.

The reviewers defined recumbent as lateral (side-lying), supine (lying), or semi-recumbent (lying with the head of the bed raised up).

The studies in the Zang et al. review took place in the United Kingdom (U.K.), Finland, Brazil, China, Ireland, Turkey, and South Africa, and the publication dates ranged from 1983 to 2017. Unfortunately, the risk of bias was unclear in 8 studies, and the risk of bias was high in 4 studies. Most of the studies had problems with randomization (selection bias), blinding (detection bias), and a few studies had problems with attrition (people dropping out of the study). As such, we need to take this review's findings with caution.

Zang et al. found that upright birthing positions led to:

Lower rate of instrumental delivery (forceps/vacuum use)

Shorter length of the active pushing phase (by 8 minutes on average)

A much shorter length of the active pushing phase when squatting was used (by 16 minutes on average)

Substantial decrease in the risk of severe perineal trauma (75% relative risk reduction; only 2 of the 12 studies reported on severe perineal trauma)

Higher risk of 2nd degree tears with the positions of squatting and sitting on a birth seat

No difference in blood loss of >500 mL between groups (in contrast to earlier reviews that found a higher risk of blood loss in upright groups)

No difference in the length of the entire second stage

The effect of birthing positions on episiotomy rates was unclear because the studies had a wide range of episiotomy rates. For example, some studies had episiotomy rates closer to 0% in both groups, while some studies had episiotomy rates of close to 90%. Because all the studies were so different, it wasn't possible to combine the results on episiotomy.

Some people may be surprised to see the higher risk of 2 nd degree tears with squatting or using a birth seat. But this can be explained by the fact that in these studies, the higher rate of 2 nd degree tears with upright births was exchanged for a lower rate of episiotomies. Since other researchers have found strong evidence that natural tears heal easier and are less traumatic to tissue than episiotomies (Jiang et al., 2017), a higher risk of second-degree tear in exchange for a lower risk of episiotomy is considered a good trade-off.

Previous researchers (Gupta et al., 2017) have noticed a higher risk of blood loss with upright birth, but this was not seen in the Zang et al. (2020) meta-analysis.

Other outcomes, such as pain, satisfaction, or use of Pitocin® to augment labor, were not examined in the Zang meta-analysis. However, results from individual randomized, controlled trials, have found additional benefits to upright birth.

For example, in 2017, Moraloglu et al. published a study with 102 people giving birth without epidurals in Turkey. Participants in this study were randomly assigned to push and give birth in a standing/squatting position holding onto a bar, or the lithotomy position with the head of the bed raised 45 degrees. The study showed that those who stood, then squatted down with a bar to push during contractions, had shorter second stages of labor by about 34 minutes. They also experienced less pain, were less likely to receive Pitocin® to augment labor, and had higher satisfaction with the birth experience, compared with the group that pushed and gave birth while back-lying with the head of the bed raised.

Other individual randomized trials have found that in people without epidurals, upright birthing positions lead to:

Significantly lower rates of pain (de Jong et al. 1997; Purnama et al. 2018)

Lower rates of shoulder dystocia (Zhang et al. 2017)

Lower rates of abnormal fetal heart tones (Crowley et al. 1991; de Jong et al. 1997)

Lower rates of emergency Cesarean (Zhang et al. 2017).

For people with epidurals, which birthing positions are best supported by evidence?

Epidural analgesia is common in many countries; for example, more than 60% of those giving birth to a single baby in the U.S. use epidural or spinal analgesia (ACOG, Practice Bulletin No. 177, 2017).

In 2018, Walker et al. published a Cochrane review that examined the evidence for upright vs. non-upright birthing positions among people with epidurals. However, since this review was dominated by BUMPES randomized trial (more than three-fourths of the Cochrane review participants came from this trial), I chose to write about the BUMPES trial instead of the Walker et al. Cochrane review.

The BUMPES trial on side-lying with an epidural vs. upright with an epidural

The BUMPES trial was a very large randomized, controlled trial on birthing positions carried out by a group of researchers in the U.K. called the Epidural and Position Trial Collaborative Group (2017). The researchers compared upright vs. side-lying birthing positions in first-time birthing people, all of whom had a low-dose epidural.

Between 2010 and 2014, a total of 3,236 people were enrolled in the study from 41 centers in the U.K. To be included in the study, participants had to be over the age of 16, pregnant with a single, head-down baby at 37 weeks or greater, planning to give birth vaginally, and in the second stage of labor with a low-dose epidural.

Since participants weren't randomized to upright or side-lying positions until the second stage of labor, this research doesn't apply to positioning with epidurals in the first stage of labor. It also doesn't tell us anything about the back-lying, semi-sitting, or lithotomy positions with an epidural.

The upright group was assigned to be moving on foot, standing, sitting, kneeling, or in any other upright position.

The non-upright group was assigned to side-lying with the head of the hospital bed raised up 30 degrees. Because they were all supposed to use the side-lying position, we will call this group the side-lying group.

About 80% of participants assigned to both the upright and side-lying groups were able to move around, meaning that they had true low-dose epidurals. For the most part, people used their assigned pushing positions.

The researchers found that fewer people assigned to upright birthing positions experienced spontaneous vaginal birth compared to people in the side-lying group (35% vs. 41%). Most participants in this study gave birth either with Cesarean or with vacuum/forceps. We were surprised to see such high rates of intervention in this study-the rate of vacuum/forceps births was 51%-55% and more than half (55%-59%) of people received an episiotomy-a procedure that is known to increase harms. These numbers are very high. In the U.S., for example, the overall rate of vacuum/forceps births is only around 3% (Martin et al., 2017).

It's not clear why people assigned to upright birthing positions were less likely to have spontaneous vaginal births in this study. The researchers did not find a difference between groups in rates of failure to progress or fetal distress leading to vacuum or forceps. They also did not find differences in any other health outcomes. It could be that people with low-dose epidurals have a greater chance of giving birth spontaneously when they use a side-lying position for the second stage of labor rather than an upright position. However, the findings from this study should be taken with extreme caution-the results may not apply to settings with more support for spontaneous vaginal birth (where there is less use of vacuum or forceps).

In two other randomized trials, researchers found evidence that the lithotomy position is harmful if you have an epidural.

In the first study on the lithotomy position with epidurals:

Researchers randomly assigned 199 participants giving birth at a hospital in Spain to a "traditional model of birth" or an "alternative model of birth" (Walker et al., 2012).

People assigned to the traditional model began pushing in the lithotomy position immediately after they reached ten centimeters and gave birth in the lithotomy position.

People assigned to the alternative model delayed pushing and gave birth in a specific type of side-lying position:

The alternative model group was instructed to change position every 20-30 minutes after reaching full dilation and begin active pushing efforts only after feeling a strong urge to push.

Hospital staff assisted them in moving into different positions like sitting, kneeling, side-lying, or hand-and-knees.

If, after 2 hours in the passive phase, the epidural prevented people from feeling an urge to push, they were asked to start pushing with each contraction.

When people in the delayed pushing group were ready to begin pushing efforts, staff assisted them into a specific side-lying position. In this position, the lower leg remained extended on the bed and the upper leg rested flexed on the stirrup. This placed the foot of the upper leg in a higher position than the knee to allow the upper hip to rotate. The birthing person's upper body was placed in a neutral position and supported with pillows, if necessary.

Those who delayed pushing and gave birth in a side-lying position were less likely to need forceps, vacuum, or fundal pressure (20% vs. 42%) and had a higher rate of intact perineum (40% vs. 12%) compared to people who pushed immediately and delivered in a lithotomy position.

There was no difference between groups in the rate of first-, second-, or third-degree perineal tears, so the lower rate of episiotomy (21% vs. 51%) in the side-lying group accounts for the higher rate of intact perineum in that group.

In the second study on lithotomy positions with epidurals:

Researchers randomly assigned 150 birthing people in Spain to position changes every five to 30 minutes in the passive phase of the second stage of labor or to a lying down position for the entire second stage (Simarro et al., 2017).

Both groups were instructed to delay pushing and everyone eventually gave birth in the lithotomy position.

The people assigned to position changes during the passive phase of the second stage of labor had better outcomes than the group that was lying down for the entire second stage, even though everyone gave birth in the same back-lying position.

The group that changed positions had fewer Cesareans (1% vs. 10%) and fewer cases of vacuum/forceps (24% vs. 39%). They also experienced shorter second stages of labor (95 minutes vs. 124 minutes) and fewer episiotomies (18% vs. 31%).

In other words, evidence continues to show today that the lithotomy position is harmful and should not be used for pushing or delivery, even in with people with epidurals.

Evidence on Birth Seats (for people with and without epidurals)

Birth seats or stools have been used for thousands of years. For example, they are mentioned in the book of Exodus 1:16:

"When you serve as midwife to the Hebrew women and see them on the birthstool..."

Recently, researchers have begun exploring the effectiveness of different types of birth stools.

The Swedish Birth Seat Trial was carried out at two hospitals in Sweden between 2006 and 2009

(Thies-Lagergren, 2013). The study included 1,020 participants giving birth vaginally for the first time between 37 weeks and 41 weeks 6 days. Nearly half (45%) used epidurals for pain relief during labor. Participants were randomly assigned to either give birth on a special birthing seat called the BirthRite seat (http://bit.ly/2FBk5a8) or in any other position.

The researcher found:

The birth seat resulted in a shorter second stage of labor by an average of 6-13 minutes, as well as less use of Pitocin® for augmentation of labor.

No difference in the rate of forceps or vacuum assistance.

People who gave birth on the birth seat were at increased risk of postpartum blood loss; however, the blood loss did not influence hemoglobin levels 2-3 months postpartum.

There was no difference between the groups as far as perineal tears, but the birth seat was linked to fewer episiotomies-2% of those who gave birth on the birth seat had an episiotomy compared to 14% of those who gave birth in other positions.

The study did not find a difference in health outcomes for mothers or infants other than the increase in postpartum blood loss. However, the participants who were assigned to give birth on the birth seat were more likely to report that they felt "powerful, protected and self-confident"-which led to greater satisfaction with childbirth.

To watch a video from Evidence Based Birth® that shows different types of birthing stools, visit here: https://www.youtube.com/watch?v=gbHujklthyo

What evidence do we have on birthing positions from observational studies?

We found three observational studies on birthing positions in the second stage of labor that have been published in the last ten years-two from Sweden and one from Italy.

Swedish Study compared "women-centered" care to standard care

The first study from Sweden looked at strategies care providers can use in the second stage of labor to improve health outcomes (Edqvist et al., 2017). Midwives treated 296 first-time birthing people with a three-part protocol called "woman-centered care," and the other 301 first-time birthing people received standard care. The use of epidurals in the study was 61%.

The group that received woman-centered care had:

Spontaneous pushing (pushing efforts were not coached or directed),

Flexible sacrum birthing positions (kneeling, standing, hands-and-knees, side-lying, birth seat)

Birth of the baby's head and shoulders in two separate contractions (for more about this evidence-based method, called the "two-step delivery method," listen to EBB Podcast Episode 168)

In contrast, the midwives who practiced standard care did not receive any special instructions.

The researchers determined that the odds of second-degree tears were less likely in those who received woman-centered care compared to those who received standard care. However, we do not know which part of the 3-part protocol contributed to the lower rate of second-degree tears.

Swedish study looks at birthing positions and severe tears

Another study also from Sweden looked at the effect of delivery position on the rate of obstetric anal sphincter injury (OASIS) (Elvander et al., 2015). These severe tears, also called third- and fourth-degree perineal tears, are related to long-term complications, such as anal incontinence, sexual dysfunction, pain, and a reduced quality of life.

The researchers included more than 100,000 people from a birth record database in the study. The database included midwives' records of which position the birthing person used during the actual birth. More than half (57%) of the first-time birthing people used epidurals and 26% of those who had given birth before used epidurals. Everyone included gave birth vaginally to a single baby, and no episiotomies were used.

The researchers found that the lowest rates of severe perineal tears occurred among people who delivered in a standing position, and the highest rates of severe tears occurred among those who delivered in the lithotomy position.

Italian study looks at birthing position and urinary incontinence

In another study, researchers in Italy explored what effect birthing positions may have on urinary incontinence (Serati et al., 2016). They conducted phone interviews 12 weeks after the birth with 296 people who used an upright position to deliver and 360 people who used a back-lying or side-lying position. To assess urinary function, participants were asked questions like: How often do you leak? How much urine do you usually leak? When does the urine leak?

The survey data showed that delivering in upright positions was related to a lower episiotomy rate (30% vs. 41%) but a slightly higher rate of third- and fourth-degree perineal tears compared to delivering in the lying down position (1.35% vs. 0%). The episiotomy rate in this study was very high, so these results may not apply to low-episiotomy settings.

Importantly, these Italian researchers found that lying down delivery positions increase the risk for postpartum urinary incontinence and of stress urinary incontinence, defined as involuntary leakage on effort or exertion or sneezing or coughing. It's possible that this increase in the risk of urinary incontinence may be related to the higher rates of episiotomies with lying down positions.

In my discussions with professionals and parents around the world, I have heard that some providers may be willing to support pushing in upright positions (passive or active second stage), but few obstetricians will attend an actual birth or "delivery" in an upright position.

For example, health care workers may support someone pushing in a squatting position, but when the baby is about to emerge, they may insist the birthing person sit back in a semi-sitting or lying back position for the delivery. They may say something like, "I need you to get onto your back right now for safety reasons" or "You don't want to tear, do you? Then get on your back right now," or "Your baby is going to get stuck under your pubic bone, unless you move right now!"

In other words, it's common to be given a vague threat combined with an urgent direction. This situation can be confusing, because parents may think it is a true emergency (which is a possibility, of course), so they almost always comply... but many times it is not an emergency, and there is nothing wrong with the birth or baby.

The coercion that some providers use to get patients to lay on their back may be due to general anxiety and fear of upright birth. Since most health care workers are not trained in true upright birth, and rarely (if ever) see one, an upright birth may make them feel nervous and uncomfortable. The easiest way to relieve these feelings of discomfort is to pressure the patient to lay on their back.

The desire for some medical staff to have the delivery happen in a "controlled" manner (non-upright position) is so strong that many birthing people have shared stories with us of either being coerced or forcibly put into non-upright positions during childbirth.

In 2016, Caroline Malatesta won a landmark court case in Alabama in which she sued her hospital for malpractice and fraud. At Ms. Malatesta's birth, the hospital nurses forcibly turned her onto her back (she was in a hands-and-knees position) during the delivery and held the baby's head in for 6 minutes until the doctor could arrive, causing a severe, lifelong, maternal nerve injury. The jury awarded a $16 million verdict in Ms. Malatesta's favor, finding that forcing a birthing person into a delivery position against their will violates the nursing standard of care, especially for un-medicated or "natural" births.

The use of forcing birthing people into the care provider's preferred position is a form of obstetric violence. In their paper describing Ms. Malatesta's case in the Journal of Perinatal and Neonatal Nursing, Pascucci and Adams (2017) state:

Obstetric violence is, in its simplest form, a form of violence against women that occurs in the childbirth setting. It is an attempt to control a woman's body and decisions and may involve coercion, bullying, threats, and withdrawal of support, as well as other violations of informed consent and physical force. Obstetric violence might manifest as forcing a woman supine because that is the doctor's preferred position for birth... Forcing someone into a particular delivery position could be viewed by the courts as negligence or battery (Pascucci and Adams, 2017).

It is best practice for hospitals, obstetric providers, and nurses to support birthing people in their right to choose positions for pushing and delivery. This does not mean that providers cannot encourage certain positions (or frequent switching of positions) if they feel that they would be helpful in specific situations-but it is unethical for a provider to use coercion or force to achieve a delivery position.

Listen to Evidence Based Birth® Podcast Episode 225 with Mandy Irby, RN, about how the lithotomy position can also be considered an unethical "restraint."

In a publication by the World Health Organization (WHO) called "Care in Normal Birth," the WHO concludes that women in labor should adopt any position they like, while preferably avoiding long periods lying down (WHO, 1996). They recommend that birth attendants get training in supporting upright births, since much of the positive effect of upright birthing positions depends on the birth attendant's experience with the position and willingness to support the patient's choice of position.

In 2017, the World Health Organization also published a document called "Managing Complications in Pregnancy and Childbirth," in which they stated the health care provider should "support the woman's choice of position during labor and birth."

In the U.S., the American College of Obstetricians and Gynecologists (ACOG) has a Committee Opinion called "Approaches to Limit Intervention During Labor and Birth." In this opinion, ACOG states that for most people, "no one position needs to be mandated nor proscribed."

ACOG also states that it is normal for people in labor to assume many different positions, and that no one position has been proven best. They cite the fact that many care providers encourage a supine position during labor even though it has known adverse effects, including low maternal blood pressure and more frequent abnormal fetal heart rates. They go on to say that continuous EFM has not improved outcomes in low risk pregnancies, and that care providers should "consider training staff to monitor using a hand-held Doppler device (intermittent auscultation)...which can facilitate freedom of movement and which some women find more comfortable."

The statement concludes with a general recommendation that care providers can support frequent position changes during labor to enhance maternal comfort and promote optimal positioning of the baby if they do not hinder monitoring and there are no complications.

In 2012, three U.S. midwifery organizations -American College of Nurse Midwives, Midwives Alliance of North America, and National Association of Certified Professional Midwives-created a consensus statement on supporting healthy, physiologic childbirth (U.S. Midwives, 2012). They stated that freedom of movement in labor and the woman's choice of birth position are essential to this goal.

The Royal College of Midwives (RCM) in the U.K. recommends the use of active and upright positions to assist with labor and delivery. In their guidelines, they urge midwives to be proactive in demonstrating and encouraging different positions in labor, since birthing people often "choose" to do what is expected of them, and the most common image of the laboring person is "on the bed."

Since the environment is key to freedom of movement, RCM suggests that there should be a variety of furniture and props available in the room to encourage people to try different positions: bean bags, mattresses, chairs, and birth balls. They recommend that midwives support clients with suggestions on how to remain upright even if they're in a situation that might limit mobility-such as with traditional EFM, intravenous (IV) fluids, and different medications for pain relief.

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Evidence on: Birthing Positions - Evidence Based Birth®

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This article focuses on the evidence for birthing positions in the second stage of labor. The second stage of labor begins when the cervix is completely dilated (open) and ends with the birth of the baby.

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Baby Being Born

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7 ways to reduce perineal tearing during childbirth

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While most expectant mothers are excited, many are also anxious about giving birth, especially first-time mothers. Perineal trauma is something many expectant mums are fearful about.

It is hard to comprehend being able to give birth to an entire human, but a woman's vagina is pretty amazing, and nature has designed it to accommodate the baby. Hormones, increased blood supply and a clever, stretchy design all play a role in making this happen. No muscles in the female body are able to stretch without rupturing as much as those of the pelvic floor.

The perineum is the soft tissue between a woman's vagina and anus, and it has the capacity to stretch significantly during birth. However, it can tear, or may be surgically cut if medically indicated and consented to by the woman (called an episiotomy).

When women have their first baby, they are more likely to have some perineal tearing. Most tears heal well and are never thought about again, but for some women there is ongoing pain and psychological trauma.

Read more: Why labour is such a pain - and how to reduce it

Perineal trauma prevalence

There are different degrees of perineal trauma (1st, 2nd, 3rd and 4th). First-degree (involves skin but not muscle) and second-degree tears (involves perineal muscles) are the most common. Third- and fourth-degree tears, known collectively as "severe perineal trauma" are more serious, as they also involve the anal area and can lead to long term consequences, such as pain and incontinence for women.

In Australia, the latest statistics show more than one in four women have no perineal tearing during the birth (more likely when not the first baby), 21% have a 1st degree tear, 30% have a 2nd degree tear and less than 3% have a 3rd or 4th degree tear (more common with the first baby).

Around 24% have an episiotomy, which is worrying as this has doubled in the past ten years (12% in 2009), and there is evidence the recovery is more painful than if the perineum tears naturally.

Read more: Episiotomy during childbirth: not just a 'little snip'

There is little doubt the rates of perineal trauma have increased over the past 100 years, with early midwife records indicating most women had no tearing.

An increase in the use of birthing interventions such as vacuum, forceps and episiotomy (which can cause further tearing), women giving birth at an older age to fewer babies, and greater vigilance by midwives and doctors when examining the perineum after birth have all played a role in the increased perineal trauma rates we see today.

Rates of perineal trauma vary across the country, with one report finding a 12-fold difference between hospitals, ranging from six per 1,000 births in some hospitals to 71 per 1,000 births in others.

This difference could come from varying hospital practices such as more frequent use of forceps and vacuum, or from the demographics of the women in a given area (more women having their first baby, or even the country of birth of the women).

How to reduce perineal tearing

There are recommendations on how to reduce the chance of perineal tearing and trauma, based in part on our research.

During pregnancy:

1) perineal self-massage (or with help from your partner) after 34 weeks of pregnancy can help protect your perineum and reduce the risk of third- and fourth-degree perineal tears

2) pelvic floor muscle training may help prepare you for labour and birth and reduce the possibility of a third- or fourth-degree perineal tear.

During a vaginal birth:

3) applying warm compresses to the perineum during the second stage of labour (when pushing and giving birth) can significantly reduce the risk of a third or fourth degree perineal tear

4) slowing the rate at which the baby's head and shoulders emerge, with the help of your birth attendants, may help prevent perineal injuries

5) perineal massage performed by your health-care professional during the second stage of labour may reduce the risk of third- and fourth-degree perineal tears. However, some women may not feel comfortable with this option, and it is not recommended for everyone

6) listening carefully to your midwife's voice and following their instructions can help the baby emerge from your vagina gently and slowly. For example, your midwife will tell you to breathe and not push just before your baby is born

7) perineal trauma is less common when women give birth in home-like environments such as at home or in a birth centre, where they have less medical intervention, can use water for pain relief and give birth in upright birth positions.

In a new paper we have also found having two midwives in the room in the late stage of birth, instead of one, can reduce perineal trauma by up to 31%. Our study found having a second midwife in the room meant one of them was focused on the woman at all times, and was not distracted by other things that needed to be done. It also meant they could give suggestions and reinforce the first midwife's words to the mother during the birth.

Read more: Vaginal birth after caesarean increases the risk of serious perineal tear by 20%, our large-scale review shows

Treatment and recovery

Following the birth, your midwife or doctor will stitch any perineal trauma that needs to be repaired in the birthing room, and these stitches dissolve over the coming weeks. Some tears are minor and do not require stitches.

Most perineal wounds heal well by resting, applying ice for the first day or two if swollen, changing sanitary pads and keeping the perineum clean, gentle pelvic floor exercises after a couple of days to help healing, and adequate pain relief.

After birth, if you have problems with your perineum, don't just put up with it. Contact your midwife or doctor to get further advice.

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7 ways to reduce perineal tearing during childbirth

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While most expectant mothers are excited, many are also anxious about giving birth, especially first-time mothers. Perineal trauma is something many expectant mums are fearful about. It is hard to comprehend being able to give birth to an entire human, but a woman's vagina is pretty amazing, and nature has designed it to accommodate the baby.

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Third Stage

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Third stage of labour: delivering placenta and cord clamping | Labour & birth articles & support | NCT

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You’ve met your baby but there’s still work to be done. Here’s what happens during the third – and, good news, the final – stage of labour…

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Third Stage of Labour

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Choosing between Active and Physiological Delivery of the Placenta
Whether you plan to give birth at home or in hospital, you can choose to have drugs to help you deliver the placenta, or to go for a 'natural' third stage.

'Active management', or a 'managed third stage', means that you have an injection as the baby is born, or shortly afterwards, which makes your uterus contract strongly to push out the placenta quickly, and then makes it clamp down tight to reduce bleeding after the placenta is delivered. In the UK, the drug most often used is Syntometrine - a combination of Syntocinon, to bring on strong contractions, and Ergometrine, to make the uterus clamp down tight afterwards.

The advantages of an actively managed third stage are that the third stage is usually over quickly, and average blood loss is lower. The mother does not usually have to 'do' anything - she just waits, while the drugs and the midwives do the work!

The disadvantages of an actively managed third stage for the mother are:-

some women feel sick, dizzy or faint or have a headache after the drug is injected, and some vomit and are unable to hold the baby for a while after birth because they feel so bad. Estimates of the proportion of mothers so affected vary from 1 in 8 to 1 in 3, so while the majority of mothers will feel fine after Syntometrine, the risk of 'minor' side-effects is appreciable.

Blood pressure changes can be significant for some women -

There is thought to be a higher risk of trapped placenta, where the placenta is stuck inside the uterus, if it is not delivered before the ergometrine component of the drug makes the uterus clamp down. If a trapped placenta occurs, it usually has to be manually removed in an operating theatre.

Active management has serious drawbacks for the baby IF the cord is clamped before it has ceased pulsating. It is not necessary for Syntometrine to be given this quickly, but usual practice in the UK is to give the injection as the baby's shoulders are born, or immediately after the birth. The cord is usually clamped before the injection is given, because of theoretical concerns about the powerful shunt of blood from the induced contractions causing an 'overtransfusion' - the baby getting too much blood, which could lead to polycythaemia (causing a serious form of jaundice). Current evidence appears to suggests that neither of these is a real risk. The downside of early cord clamping is that the baby does not get the benefit of the oxygen-rich blood in the cord and placenta which would come to it in a natural third stage. This is now known to increase the baby's risk of becoming anaemic in infancy. Moreoever, the oxygenated blood in the cord and placenta would normally tide the baby over for the few minutes while the cord pulsated, providing extra oxygen while the baby established breathing. This cord blood is rich in stem cells, and we do not yet know if these have a role to play in recovery from birth.

Delaying cord clamping for a few minutes after the baby is born is now becoming rather mainstream, thankfully; the Daily Mail has even published an article on it!

Another recent article by a US obstetrician, Nicholas Fogelson MD, discusses ' Why delayed cord clamping should be standard practice in obstetrics'. The comments section is extensive and well worth a read, containing input from midwives, doctors and birth supporters from varied backgrounds. Follow-up articles and video presentations are also available.

See also the Facebook page - Delayed Cord Clamping UK.

For more discussion of the effects of early clamping on the baby, see Cordclamp.com - retired obstetrician George Morley has specialised in compiling information about the best way of managing cord clamping, and of the risks associated with early clamping.

Much of the research on cord clamping is fairly recent and practices in obstetrics are only just starting to change. It is now being questioned whether early clamping is indeed necessary after an injection of syntometrine, but as early clamping is currently standard practice, you may find that your caregivers are either not up to date with the latest research, or disagree with it. This is changing rapidly in the care of premature babies, and is starting to filter through to the mainstream.

Here, for example, is a quote from a letter to the BMJ from a consultant obstetrician, explaining why his unit has changed arrangements so that they can resus after caesareans with the cord still attached:

From http://www.bmj.com/cgi/eletters/333/7575/954 "Fetal distress is a common reason for instrumental delivery or caesarean section. The fetal compromise is often due to cord compression associated with a nuchal cord. A nuchal cord results in compression of the low pressure venous return of oxygenated blood from the placenta. Blood continues to be pumped out by the fetal heart and the obstructed return from the placenta results in a congested placenta and a depleted fetal blood volume.
If the cord is clamped immediately at delivery, although the return from the placenta is now relieved, the excess blood, which is oxygenated blood, never has any opportunity to return to the newborn.
In these circumstances it is particularly important to be able to resuscitate the baby with the cord return still intact. Preparation for neonatal resuscitation needs to be made at the same as preparation for the caesarean section. Every maternity unit in the UK needs to adopt these guidelines.
David Hutchon

There are quite a few other interesting letters on that BMJ letters page, with a number of references to research on cord clamping and anaemia etc..
The Journal of American Medical Association published a meta-analysis of early versus late cord clamping in full-term newborns, which you can read in full here:http://jama.ama-assn.org/cgi/reprint/297/11/1241
They found that there was no increase in the incidence of clinical jaundice or need for phototherapy with 'late' cord clamping, although there was some increase in neonoatal polycythaemia. In the higher-quality studies this association did not reach statistical significance.

What they DID find was that late clamping was associated with better iron status, as measured by serum ferritin levels, to six months and beyond, and also with less anaemia in the newborn periods. The babies who were breastfed and who experienced 'late' cord clamping had proportionately higher iron stores at six months than the babies who were no longer breastfed.

Abstract copied below.
See also NHS electronic library for health discussion of the paper
http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?View=Full&ID=12007008099

This subject is returned to in the section below on resuscitation with the cord intact.

'Physiological management', or a 'natural' third stage, means that drugs are not automatically administered to deliver the placenta, but that the woman waits for it to arrive naturally, and drugs can be given at any time if blood loss seems worrying or if she decides she has waited long enough. If, at any stage, the woman's blood loss worries her or her midwives, she still has the option of having drugs to push out the placenta and control bleeding.

The downside of a 'natural' third stage is that it takes longer to deliver the placenta, on average, and that average blood loss is higher. The Hinchingbrooke trial of active management versus physiological third stage found that 16.5% of women had a clinically significant blood loss of 500mls or over with physiological management, against 6.8% with active management. But when you look at the overall difference in blood loss, as opposed to the number of women who passed that threshold, it was only an average of 80mls approximately (if I recall correctly - will confirm that soon) [Rogers et al, 1998]

How long does a physiological third stage take?

Perhaps not as long as you might think. Research suggests a physiological third stage takes only 9.7 minutes longer than active management, on average [4, Cochrane review]. Yet it is quite common for a natural third stage to take half an hour or an hour or more, although ten minutes is also perfectly normal. Why should it have a reputation for taking so long? In a discussion on third stage [LINK currently DOWN while that site is restructured], a UK midwife commented:

In most normal cases, a placenta will detach from the wall of the uterus within ten minutes (whether you give an oxytocic or not.) Ultrasound studies show this. Sitting around for a couple of hours waiting for the thing to fall out after it has separated is dull, and can be dangerous.

What almost always happens, if you watch carefully and disregard the things you think you know about third stage, is this. The baby is born and the cord pulsates forcefully. The mother greets the baby and gives him or her her full attention. Within three to five minutes she will have a contraction and will usually look up and go 'ooh.' Within five to ten minutes she will have another, nasty contraction and go 'ow,' and whatever she is doing she'll normally shift around uncomfortably. This is because the placenta has hit her cervix. If you feel the cord, then, it may be pulsating, but the pulsation will be weak and thready. If she is in, or gets in an upright position, the placenta will normally plop out. Well within fifteen to twenty minutes.

So what is different about a natural third stage? The mother has to be actively involved in the birth of her placenta; she must push it out herself, and sometimes this involves moving around, and trying different positions and techniques, although, as the experiences below show, it often takes no more than standing up as the placenta slips out. Your baby can be close to you while you are doing this, of course, and for many women a physiological third stage means no more than sitting down,and cuddling the baby for ten minutes or so until she feels the urge to push the placenta out.

While you are waiting, your midwives should observe carefully and may offer advice on techniques to help push the placenta out. For instance, some women find that if they push as if they were trying to do a poo (bowel movement), the placenta rapidly appears. Some midwives recommend that women blow into a bottle to help push the placenta out. A full bladder can make it difficult to pass the placenta; if you find it difficult to urinate, you could try a warm shower or bath, or your midwives may catheterise you.

If you do not have drugs to aid delivery of the placenta, you can choose to either have the cord cut when it has stopped pulsating, or to wait until the placenta is delivered. This last choice is a great excuse to keep your baby 'velcroed' to you straight after birth, rather than having him whisked off to be weighed and measured while you get on with delivering the placenta. On the other hand, some women feel they can't concentrate on delivering the placenta while still attached to their baby. There is some speculation that leaving the cord uncut until the placenta is delivered might somehow help speed up the delivery of the placenta, but I am not aware of any strong evidence for or against this.

I have had physiological third stages for all of my five babies, but while the cord was cut when it stopped pulsating after the first, I left it intact until the placenta was delivered for the others. Personally I really valued the peaceful bonding time this latter choice gave me and my babies. The first time it took about an hour and a quarter and was unpleasant - the cord was cut when it stopped pulsing, and I spent ages sitting there, cold, trying to push the placenta out, while clots built up behind it. The midwives were very relaxed about natural third stages and believed that it was normal for them to take an hour on average. The placenta was separated but I could not feel any contractions to push it out, and eventually passed a large amount of blood clots which had built up inside me behind the placenta, before the placenta came out. After that I swore that I would choose a managed third stage next time, because I felt that precious first hour with my baby had, instead, been spent trying to have a placenta. However, after reading about different approaches to a physiological third stage I decided to be more proactive next time, and it worked beautifully; none of my subsequent third stages took more than 20 minutes, several less than 10, and during that time I was snuggled up with baby having a nice cup of tea! Blood loss was minimal. I had decided that, if the placenta did not arrive within 15 minutes or so, I would ask the midwife for help delivering it and, if that did not get results quickly, have the injection. What worked for me was pushing as if I was having a bowel movement, as soon as I started to feel anything at all!

Michel Odent apparently teaches that it is important to keep oxytocin production up in the third stage, in order to help push the placenta out and contract the uterus down. Things which help this:

Keep warm - ideally mum and baby wrapped up together under a duvet or blanket

Keep the room calm, quiet, low lights

Personally I worry about staying in a birth pool for the third stage because I believe that we hear about more long and difficult third stages when this happens. It may be that the birth pool relaxes some women too much and it is difficult to get strong enough contractions for the third stage. It can be hard for the midwife to keep an eye on blood loss, particularly if the room is dark. A third stage in water can be hassle for other reasons; it can certainly be difficult to keep both mum and baby at a comfortable temperature and to give the baby its first feed, while ensuring that both water level and water temperature are perfect. There is some discussion about this on the page about waterbirth, but I plan to expand on it soon. I am not aware of any research evidence on the safety of conducting the third stage in water, and while certainly many women do it with no problems, it seems reasonable to question it; it's certainly not something we have evolved to do.

Please see the section above on ' Cord clamping - issues for the baby'.

If the baby needs some form of resuscitation, this can be administered while the baby is still attached to the cord - giving it the benefit of all the oxygenated blood in the placenta, as some still pulses down the cord for a few minutes after birth - if the midwife has her equipment near the mother, or if the mother can move to the resus area. If the mother cannot move to the resus area then the midwife can quickly clamp and cut the cord, just as she would in a managed third stage. However, the disadvantage of this is that the baby is deprived of the oxygenated blood which is already in the cord and placenta, and which would be transfused to the baby over the next few minutes - buying it vital time to establish breathing. Increasingly, experienced midwives and obstetricians are resuscitating with the cord attached wherever possible.

The British Medical Journal's editorial on 18 August 2007 focussed on this issue, and concluded:

"Early clamping and cutting of the umbilical cord is widely practised as part of the management of labour, but recent studies suggest that it may be harmful to the baby. So should we now delay the clamping? ..."

"How should we approach cord clamping in practice? In normal deliveries, delaying cord clamping for three minutes with the baby on the mother's abdomen should not be too difficult. The situation is a little more complex for babies born by caesarean section or for those who need support soon after birth. Nevertheless, it is these babies who may benefit most from a delay in cord clamping. For them, a policy of "wait a minute" would be pragmatic.11 Indeed, this first minute is already largely spent on neonatal assessment. This could be done in warmed towels on the birthing bed or the mother's abdomen after vaginal delivery, or on the mother's legs at caesarean section. Cord clamping need only take place when transfer to the resuscitation trolley is required.... "

"There is now considerable evidence that early cord clamping does not benefit mothers or babies and may even be harmful. Both the World Health Organization and the International Federation of Gynecology and Obstetrics (FIGO) have dropped the practice from their guidelines. It is time for others to follow their lead and find practical ways of incorporating delayed cord clamping into delivery routines. In these days of advanced technology, it is surely not beyond us to find a way of keeping the cord intact during the first minute of neonatal resuscitation. "

You can read the full text of the BMJ Editorial on Cord Clamping online: BMJ Cord Clamping editorial - pdf
BMJ Cord Clamping editorial - .rtf
Please see Links section below for more links to the original editorial, and to responses from midwives and obstetricians.

More information on resuscitation at homebirths, and birth stories where resus has been given in different ways, can be found on What if your baby needs resuscitation at home?

An excellent article explaining many of the arguments against routine intervention in the third stage is: Third Stage of Labour Benefits of A Natural Approach, By Dr Sarah J Buckley
http://www.bellybelly.com.au/articles/birth/natural-approach-to-labour

Here is an extract from the page on Birth Plans, about choices for third stage:
There are four main variations to choose from, but of course if the midwife is worried about your blood loss then (with your permission or without, in an emergency) drugs may be needed, whatever your plans.
I plan to have an actively managed third stage and understand that the midwife will administer syntometrine/syntocinon/whatever drug is used in her practice, when she feels it appropriate, and that the cord will be clamped and cut soon after the baby's birth.

Or: I would like an actively managed third stage, but with cord clamping and cutting delayed until the cord has stopped pulsating. After this, I would appreciate it if you could administer drugs to help me deliver the placenta.

Or: I would like a physiological third stage with the cord clamped and cut when it stops pulsating. I wish no drugs to be used unless specifically indicated. It is important to me that you do not clamp the cord until it has stopped pulsating, unless you need to take emergency steps which preclude this. **Please do not pull on the cord or use fundal pressure unless there is a specific indication to do so, as I have read that this is contra-indicated in drug-free third stages**.

Or: I plan to have a fully natural (physiological) third stage, and to cut the cord only after the placenta is delivered. I want to allow the placenta to turn up in its own time. It is important that the cord is not clamped or cut until the placenta is delivered. Please do not administer any drugs unless you feel there is a real need. I would appreciate your advice to help me deliver the placenta naturally. **Please do not pull on the cord or use fundal pressure unless there is a specific indication to do so, as I have read that this is contra-indicated in drug-free third stages**.
Here are some birth stories from women who chose various approaches to the third stage of labour at home births:
Helen H started off with a physiological third stage but opted for the injection after 20 minutes or so - her placenta came quickly. Her second baby was born before the midwife arrived after a rapid labour, and "We were just about to discuss 3rd stage labour when nature answered the question for us. Plop! Out came the placenta and sploshed onto the floor."

Gina R had a 5-hour third stage after a long, tough labour with her first baby. After trying various positions and homeopathy, she delivered the placenta with syntometrine. She went on to have a Lotus third stage, with the placenta separating after two and a half days.

Lynne D had a long third stage in a birth pool and moderate blood loss.

Emma Barrett had 'expectant management'; she hoped for a physiological third stage, but the midwife was worried about her bleeding shortly after the baby's birth, and so switched to a managed third stage.

Amanda B: While Dennis was in my arms, the I received the injection and the midwife tugged on the cord. I felt really scared at this point as it was the only part of the labour that I didn't feel I was in control. However, the placenta just slid out easily and I didn't feel a thing.

Brenda: "I decided to get out of the pool for the third stage, and wobbled to the sofa to gaze in besotted admiration at my baby, and await the placenta while Henry latched on. Then - oh, bum! More contractions. "Why am I having a physiological third stage again?" I wondered. However, I knew perfectly well why I was having one - and about one contraction later, I realised it might help if I moved my big bottom off the sofa, as sitting down was probably not the most conducive position. Sure enough, the moment I moved, out it came - masterfully caught by a midwife with a kidney dish and reflexes a rattlesnake would be proud of."

Rosie Evans wanted to wait and see how the third stage went, before deciding on a management plan. Her daughter's cord was clamped and cut after a minute or so because the midwives wanted to give her some resus out of the pool, and after that: "After a few minutes holding her in the water I decided to have the injection for third stage because I wanted to get out of the pool and into bed ... Six or seven minutes after the injection nothing had happened so with a little help I stood up, and just as I did the placenta fell out.."

Rebecca had wanted the cord left to pulsate, but the midwife didn't realise this and clamped it immediately. Her daughter was a little slow to get going, but was OK in the end. Rebecca writes: "I waited 10 minutes or so for the placenta then took the syntocinon injection to bring it on. Out it came, whole and fine. I lay with my baby and sang a song to her we'd shared when I was pregnant."

Emma: We waited for the cord to stop pulsing, and whilst waiting mummy cuddled and tried to feed. Daddy then cut the cord, after which Daddy had a chance to have a cuddle, after the vitamin K injection had been administered. I was told I would have to get out of the pool for the third stage. And although I had decided not to have the injection, I did change my mind, I was so tired and just wanted it over with. This again was relatively painless and then I was given my baby back and I was a mummy.

Joy bled heavily as her baby was born, but she wanted her baby to benefit from a physiological third stage. She stopped the midwife from clamping the cord, waited for cord to stop pulsing then had syntometrine, which was very effective.

Donna Cummings had a managed third stage in an unhurried way - her baby was born, they said hello, the midwives rubbed him down and then she had the injection.

Amber: "I wanted a physiological third stage, so after about half an hour the midwife asked if I could stand up to see if the placenta would arrive with the help of gravity, but it was a bit more stubborn than that and didn't arrive for another half an hour with a bit more pushing from me. I wasn't concerned but the midwife was getting a bit edgy, and at one point after examining me said she could see the placenta just sat waiting for me to give a shove, and she tugged a bit on the cord. This was naughty as with a natural third stage she should have been hands-off had the cord come away this could have caused complications, but as it was everything was fine and I had estimated blood loss of 300ml."

Kate Marshall waited for the cord to stop pulsing, then had the jab: "I had initially planned to try for a physiological third stage with the cord to be cut once it has stopped pulsating but had indicated that I would be willing to have the injection if required. Given the epic duration of the stop start labour and my general exhaustion the midwife had already asked me earlier if I would consider the injection once the cord had stopped pulsating and I had agreed that things had really gone on long enough. Once the cord stopped pulsating my husband cut it. ..The midwives administered the injection to deliver the placenta and asked me to lay down (as it later transpired they were concerned about the bleeding). The third stage took a total of 5 mins."

Rachel White had a homebirth after two caesareans: "We waited for the cord to stop pulsing before Curtis cut it. We tried for a physiological third stage but blood was gushing so had the injection and delivered the placenta."

Victoria Whitworth chose a physiological third stage; her midwives said they would like her to have syntometrine after an hour, but the placenta turned up after 59 minutes.

Kirsty Crowther had a natural third stage but her placenta was a bit slow, so on her midwife's advice, she delivered it by pulling on the cord herself.

Fiona's placenta took over an hour to arrive naturally with both of her babies. Her midwife encouraged to stand up and try a soothing shower, which did the trick.

Debbie Dooley chose a physiological third stage partly because she is diabetic and her research suggested this would help to stabilise her baby's blood sugar levels. The delivery of the placenta took some time but was not a problem: "We left his cord to stop pulsing and he had his first feed whilst he was still attached to me. Daddy cut his cord around 15 minutes later and had his first cuddle whilst I started pushing again to deliver the placenta. It took about an hour for the placenta to come out naturally, and Caiden fed wonderfully and helped it to detach."

Jem had an unusually painful third stage after the birth of her fourth baby. She did not have syntometrine, and "the midwives said later that it was just as well I hadn't had it, if anything had caused my uterus to contract down any harder I would have been in far more pain, which really doesn't bear thinking about."

Melanie Renowden chose a managed third stage: "I lay down on the bed and had a lovely cuddle while the midwife gave me the injection for the placenta. It was delivered very quickly and easily."

Sally Paech picked up her baby to give her her first cuddle. "I think time stood still while we all marvelled at what had just happened. What seemed like ages after I felt something "drop" from inside me. I again went up on my knees only to have the placenta drop out. Apparently it was only minutes."

Kirsty Nicol gave her body a chance to deliver the placenta on its own, but after waiting a while she moved to a managed third stage: "the placenta just didn't seem to want to budge, and after kneeling up at one point, I suddenly felt hot and dizzy. Quickly the midwives had me lying down, and I was feeling willing to go for the assisted 3rd stage after all." - after which her placenta arrived quickly and easily.

Jeanette was keeping an open mind about her third stage, and after the birth she started to bleed heavily so her midwife suggested an injection of syntometrine, which she had and which worked well. When she had her next baby, Sidney, she was again keeping an open mind, but felt so rotten after the birth that she couldn't stand the thought of waiting for a physiological third stage, and so chose syntometrine again.

Rebecca planned a physiological third stage but, after over an hour "In the end I decided that I had had enough, wanted to get into bed and lie down so I asked for a shot of syntometrine. After this the placenta came out very easily"

Gillian chose physiological management for her third stage, but her midwives were not experienced in hands-off approach, and started hassling her to deliver it in strict time limits. When an hour was up, she used homeopathic remedies, apparently to great effect.

Lonnie Fletcher chose active management after the birth of her second baby, Eloisa, and physiological third stage after the birth of her fourth baby, Aoife.

Sarah Sadler had a home birth and wanted a physiological third stage, but after waiting for the placenta for an hour, decided to use Syntometrine instead.

Brigett English said "I had planned to deliver the placenta naturally, but all I wanted to do was to be with my baby. So the placenta is delivered with the help of an injection.."

Christine chose to have Syntometrine for the third stage of her twins' waterbirth, but it made her sick.

Catriona considered a natural third stage for her third and fourth babies, after unmedicated labours, but each time chose to have syntometrine to get the delivery of the placenta over quickly.

Karen had a natural third stage with her second baby, Lewie, after having had a retained placenta with her first baby.

Kedi had planned to delay cutting the cord until the placenta was delivered, after Beth's home waterbirth, but in the event she wanted to get it over with, so chose to have the cord cut when it stopped pulsating. When her third baby, Isaac, was born, she again wanted to delay cord cutting, but this time the delivery of the placenta took two hours and was quite difficult.

Helen
was just getting bored waiting for her placenta to turn up, when it decided to co-operate.
Vivienne writes that " I'd asked for a physiological third stage and amazingly, it was all over and done with just five minutes after Gabriel was born"

Emily had a fully physiological third stage, minimal blood loss, and cut the cord after the placenta was delivered.

Sarah Calvert waited half an hour for the cord to stop pulsating before cutting it, and then her placenta arrived naturally one hour later.

Emma planned a homebirth for her twins, but transferred to hospital for slow progress. Her waters were broken in hospital, then she gave birth to her twins under her own efforts and had a physiological third stage with very little blood loss.

Tric was dreading the third stage after finding the delivery of the placenta difficult in her three previous hospital births, but with the encouragement of her confident midwife, she delivered it very easily after her waterbirth. She did not have syntometrine for the delivery of the placenta, but because of heavy bleeding she was given the drug afterwards - a "wait and see" third stage.

Carrie planned a physiological third stage but consented to syntometrine when there was a gush of blood after her baby's birth - another good example of "expectant management".

Aida chose a 'lotus' third stage for her baby - the cord was left uncut, with placenta attached, until it separated naturally from the baby. Baby Maia was born in poor condition and needed resusctiation, but this was done with her still attached to her mum.

Sara Gonzales had hospital births with managed third stages for her first two children, and chose an injection of syntometrine for her homebirth as well, as she did not want to wait for the placenta or have to push it out. She had no problems and did not experience any pain when her midwife used cord traction to help her deliver the placenta.

Helen O'Donnell had a physiological 3rd stage with no problems: " I just squatted and I think it just fell out!"

Alicia waited until her first baby's cord stopped pulsating before clamping and cutting. "About ten minutes later I stood up and delivered the placenta, no problem at all. "

Sarah H writes: "My contractions completely stopped once the baby had arrived. I had chosen to have natural third stage and wanted to have time to cuddle my baby, but the midwife was very keen that I get on and finish the job. As there did seem to be a lot more blood in the pool after this birth than the last, I did eventually agree to stand and try pushing the placenta out which worked fine.

Fiona B's second baby arrived very quickly, but her placenta was not in such a hurry: "This took just over an hour, which was starting to worry us, but the threat of a transfer to hospital gave me the incentive to push harder, and it was all fine."

Willow says that immediately after her daughter's birth, "I asked for the injection to speed up the delivery of placenta. I had romantically hoped to breastfeed instantly and slip it out like a real mammal, but in reality I just wanted birth over with.". She had no problems with her managed third stage and it took 13 minutes.

Jessica B: "I intended to get out of the water to have a physiological 3rd stage but I was enjoying cuddling this wailing child and didn't want to leave the pool. ...I was just planning on getting out when I had 3 strong but painless convulsions in quick succession & the placenta fell out to the bottom of the pool. James' cord was subsequently clamped and cut and we got on to dry land again."

Rosie had a 'wait and see' third stage: "I had wanted a natural third stage, but the placenta didn't want to shift. The MW's encouaged me to go to the loo..I sat there for ages, but it really wasn't happening, so I then shuffled back to my bed and had the injection. The placenta followed a couple of minutes later."

Miriam had a home waterbirth with her first baby, and ten minutes later stepped out of the birth pool and delivered her placenta with "no fuss whatsoever"; she had a natural third stage and the midwife simply pulled gently on the cord. Her estimated blood loss was 250mls, which is about average.
Angela Horn
Postpartum Haemorrhage - how would PPH be treated at a home birth? (on this site)

The Third Stage of Labour, from the UK Midwifery Archives - active versus physiological management, and other topics (www.radmid.demon.co.uk/pph.htm)

Review of the Literature on Umbilical Cord Clamping - by Judith Mercer
Journal of Midwifery and Women's Health, November 2001

Why early cord clamping at birth must stop now! By Dr David Hutchon (a UK obstetrician)

Cordclamp.com - retired obstetrician George Morley has specialised in compiling information about the best way of managing cord clamping, and of the risks associated with early clamping. His site is now archived on Dr Hutchon's site - this is the direct link to it.

Third Stage of Labour Benefits of A Natural Approach, By Dr Sarah J Buckley
Fab article drawing together the evidence and arguments in favour of a physiological third stage.
http://www.bellybelly.com.au/articles/birth/natural-approach-to-labour

You can read the full text of the BMJ Editorial on Cord Clamping online:
BMJ 2007;335:312-313 (18 August), doi:10.1136/bmj.39282.440787.80
Late vs Early Clamping of the Umbilical Cord in Full-term Neonates
Systematic Review and Meta-analysis of Controlled Trials
Eileen K. Hutton, PhD; Eman S. Hassan, MBBCh
Editorial on the BMJ Website - subscribers only until August 2008 (http://www.bmj.com/cgi/content/extract/335/7615/312)
Responses to BMJ - includes interesting comments from midwives and obstetricians - free to all on the BMJ website. Copy of BMJ Cord Clamping editorial - pdf
Copy of BMJ Cord Clamping editorial - .rtf

Delayed clamping of the umbilical cord does no harm and reduces anaemia in newborns
BMJ 2006;332 (13 May), doi:10.1136/bmj.332.7550.0-e

Journal of the American Medical Association
JAMA. 2007;297:1241-1252.
Context
With few exceptions, the umbilical cord of every newborn is clamped and cut at birth, yet the optimal timing for this intervention remains controversial.

Objective
To compare the potential benefits and harms of late vs early cord clamping in term infants.

Data Sources
Search of 6 electronic databases (on November 15, 2006, starting from the beginning of each): the Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Neonatal Group trials register, the Cochrane library, MEDLINE, EMBASE, and CINHAL; hand search of secondary references in relevant studies; and contact of investigators about relevant published research.

Study Selection
Controlled trials comparing late vs early cord clamping following birth in infants born at 37 or more weeks' gestation.

Data Extraction
Two reviewers independently assessed eligibility and quality of trials and extracted data for outcomes of interest: infant hematologic status; iron status; and risk of adverse events such as jaundice, polycythemia, and respiratory distress.

Data Synthesis: The meta-analysis included 15 controlled trials (1912 newborns). Late cord clamping was delayed for at least 2 minutes (n = 1001 newborns), while early clamping in most trials (n = 911 newborns) was performed immediately after birth. Benefits over ages 2 to 6 months associated with late cord clamping include improved hematologic status measured as hematocrit (weighted mean difference [WMD], 3.70%; 95% confidence interval [CI], 2.00%-5.40%); iron status as measured by ferritin concentration (WMD, 17.89; 95% CI, 16.58-19.21) and stored iron (WMD, 19.90; 95% CI, 7.67-32.13); and a clinically important reduction in the risk of anemia (relative risk (RR), 0.53; 95% CI, 0.40-0.70). Neonates with late clamping were at increased risk of experiencing asymptomatic polycythemia (7 studies [403 neonates]: RR, 3.82; 95% CI, 1.11-13.21; 2 high-quality studies only [281 infants]: RR, 3.91; 95% CI, 1.00-15.36).

Conclusions
Delaying clamping of the umbilical cord in full-term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy. Although there was an increase in polycythemia among infants in whom cord clamping was delayed, this condition appeared to be benign.

Author Affiliations: Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario (Dr Hutton); and The Child and Family Research Institute (Dr Hutton), Western Regional Training Centre for Health Services Research (Dr Hassan), and Department of Health Care and Epidemiology (Dr Hassan), University of British Columbia, Vancouver.

[4] The Cochrane review of active management for third stage says physiological third stage takes an average of 9.7 minutes longer than active management. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000007/frame.html
This page updated 22 January 2010.
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Home Birth Reference Page
Site Contents

www.homebirth.org.uk

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Choosing between active and physiological delivery of the placenta

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Discover here, in our informative website the benefits and reasons behind the push towards the mindset of "WaitforWhite and Optimal Cord Clamping" in new born babies.

How can it benefit our children?

Why should it become the normal procedure in child birth?

What can you do to ensure a healthy start for your baby?

Find out here the answers to these questions and many more...

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Discover here, in our informative website the benefits and reasons behind the push towards the mindset of "WaitforWhite and Optimal Cord Clamping" in new born babies. How can it benefit our children? Why should it become the normal procedure in child birth? What can you do to ensure a healthy start for your baby?

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Position Of Pelvis

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There are different types of labour and birth positions. We encourage you to try different positions during all stages of your labour to help your baby's head to descend (move downwards through your pelvis), encourage your labour to progress; and help you to feel more comfortable.

You can try different positions that offer different benefits for labour and birth. Your Midwife is there to help you if you need any advice, and will let you know if another position is recommended to be best for you and your baby.

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There are different types of labour and birth positions. We encourage you to try different positions during all stages of your labour to help your baby's head to descend (move downwards through your pelvis), encourage your labour to progress; and help you to feel more comfortable.

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Positions for Labour

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Stages Of Labour and Breathing Techniques

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Antenatal Breathing and Relaxation for Labour

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Dancing Through Labour

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Pregnant Woman Dances 'Tootsie Roll' to Lessen Labor Pains

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Bu videoyu YouTube Video Düzenleyicisi (http://www.youtube.com/editor) ile oluşturdum Source:https://www.facebook.com/connell.cloyd/videos/10100679392438918/ A soon-to-be mother found a creative and entertaining way to beat the pains of labor, and the resulting video has become a viral Internet sensation.

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Vaginal Examinations in Labour - why are they offered and do we need to have them?

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Massage Techniques

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The Golden Hour

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You and your baby are covered with a blanket. The baby's head stays out. The baby is naked and not wrapped. You and your baby will rest skin to skin for an hour or two after birth. This is a special time for you and your baby.

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All parents are offered a thorough physical examination for their baby within 72 hours of giving birth.
The examination includes screening tests to find out if your baby has any problems with their eyes, heart, hips and, in boys, testicles (testes).

Coronavirus update

Newborn screening appointments and vaccinations are continuing as normal, including the:

newborn blood spot test

newborn hearing screening test

newborn physical examination

It's important to go to your appointments unless you, your baby or someone you live with has symptoms of coronavirus.

What is the newborn physical examination?

The newborn physical examination is usually carried out in hospital before you go home.

Sometimes it's done at a hospital or community clinic, GP surgery, children's centre or at home.

Ideally, both parents should be there when the examination is done.

The health professional doing the examination should explain what it involves.

This could be a doctor, midwife, nurse or health visitor who's been trained to do the examination.

Some parts of the examination may be a bit uncomfortable for your baby, but it will not cause them any pain.

The aim is to spot any problems early so treatment can be started as soon as possible. Usually, nothing of concern is found.

If the health professional carrying out the examination does find a possible problem, they may refer your baby for more tests.

You'll be offered another physical examination for your baby at 6 to 8 weeks, as some of the conditions it screens for can take a while to develop.

This second examination is usually done at your GP's surgery.

How is the newborn physical examination done?

The health professional will give your baby a thorough physical examination.

They'll also ask you questions about how your baby is feeding, how alert they are, and about their general wellbeing.

Your baby will need to be undressed for part of the examination.

During the examination, the health professional will also:

look into your baby's eyes with a special torch to check how their eyes look and move

listen to your baby's heart to check their heart sounds

examine their hips to check the joints

examine baby boys to see if their testicles have descended into the scrotum

What does the newborn physical examination check for?

The examination includes an overall physical check, plus 4 different screening tests.

Eyes

The health professional will check the appearance and movement of your baby's eyes.

They're looking for cataracts, which is a clouding of the transparent lens inside the eye, and other conditions.

About 2 or 3 in 10,000 babies are born with problems with their eyes that need treatment.

But the examination cannot tell you how well your baby can see.
Find out how cataracts are diagnosed and treated
Heart

The health professional will check your baby's heart. This is done by observing your baby, feeling your baby's pulses, and listening to their heart with a stethoscope.

Sometimes heart murmurs are picked up. A heart murmur is where the heartbeat has an extra or unusual sound caused by a disturbed blood flow through the heart.

Heart murmurs are common in babies. The heart is normal in almost all cases where a murmur is heard.

But about 1 in 200 babies has a heart problem that needs treatment.
Find out more about diagnosing and treating heart problems in newborns
Hips

Some newborns have hip joints that are not formed properly. This is known as developmental dysplasia of the hip (DDH).

Left untreated, it can cause a limp or joint problems. About 1 or 2 in 1,000 babies have DDH that needs to be treated.
Find out more about developmental dysplasia of the hip
Testicles

Baby boys are checked to make sure their testicles are in the right place.

During pregnancy, the testicles form inside the baby's body. They may not drop down into the scrotum until a few months after birth.

In about 1 in 100 baby boys, the testicles only descend partially or not at all.

This needs to be treated to prevent possible problems later in life, such as reduced fertility.
Find out more about undescended testicles

Does my baby have to have the examination?

The aim of the examination is to identify any of the problems early so treatment can be started as soon as possible.

It's strongly recommended for your baby, but not compulsory.

You can decide to have your baby examined and screened for any or all of the conditions.

If you have any concerns, you should talk to your midwife or the health professional offering the examination.

When will we get the results?

The health professional carrying out the examination will give you the results straight away.

If your baby needs to be referred for more tests, they'll discuss this with you there and then, too.

The results will be recorded in your baby's personal child health record (red book).

You'll need to keep this safe and have it to hand whenever your baby sees a health professional.

If you have any concerns, you can discuss them with your midwife or the health professional who does the examination.
Download a leaflet about screening tests for you and your baby

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All parents are offered a thorough physical examination for their baby within 72 hours of giving birth. The examination includes screening tests to find out if your baby has any problems with their eyes, heart, hips and, in boys, testicles (testes).

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Is a Hat Necessary on a Newborn?

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Is a hat that utmost essential item which must be applied to every new-born head?
No. See above!

Skin to skin contact means mom and baby in skin-to-skin contact. Without physical barriers between them. The hat seems almost an obsession in some regions. I've even seen hats used during water birth, with an attendant placing the hat as soon as the baby emerges from the water! In spite of steam visibly curling from the water's surface, the hat was provided in reaction to the fear of the baby "getting cold"!

A hat is a physical and emotional barrier between the woman and her baby. It restricts her view, it may restrict the baby's view. The hat reduces tactile sensation for both; the touch and feel of the baby's hair,the feel of the mothers arm. It reduces scent sensation. It can inhibit the natural instinct many women have of wanting to rub their baby's head, or nuzzle their ears. Many mothers instinctively stroke the back of their baby's head. With a hat on, they are stroking cloth instead. Neither of them can feel it as they should.

We use hats because we want to reduce the risk of hypothermia, but we now know the best prevention for hypothermia is skin-to-skin contact of mother and baby. Without any barriers. Not even hats!

Here is one more bit of information to help you decide about hats; a hat has almost no
effect on heat preservation.

The gauze hats ubiquitous in hospitals and birth kits, don't work: "10 infants were studied while wearing a tubegauze hat at environmental temperatures of 28.5 (+/- 0.5) degrees C. This type of hat gave no measurable thermal protection."*
The cochrane database did a review of studies on Skin-To-Skin contact and had some intriguing conclusions: Women who had early Skin-To-Skin contact with their babies showed positive effects on early breastfeeding, and longer duration of breastfeeding compared to women who experienced the usual hospital routines. They also scored higher on tests for maternal attachment. The review concludes that early skin to skin contact: "May benefit breastfeeding outcomes, early mother-infant attachment, infant crying and cardio-respiratory stability, and has no apparent short or long-term negative effects."** Photo: cincinnatibirthphotography, docubirth, Calla Evans Photography, heathercookelliott, bayleerobertsonphotography, sarapanman, Melissa Cate, fermontfotografie, tamarakenyon, catherinehilcove "Early skin-to-skin contact (SSC) begins ideally at birth and involves placing the naked baby, covered across the back with a warm blanket, prone on the mother's bare chest <...> This time may represent a psychophysiologically "sensitive period" for programming future behavior."
* Head insulation and heat loss in the newborn. Stothers JK. Arch Dis Child. 1981 Jul;56(7):530-4.
** Early skin-to-skin contact for mothers and their healthy newborn infants. Moore ER, Anderson GC, Bergman N. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003519.

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Routine: the hat! - ibirthtoday education project

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Is a hat that utmost essential item which must be applied to every new-born head? No. See above! Skin to skin contact means mom and baby in skin-to-skin contact. Without physical barriers between them. The hat seems almost an obsession in some regions. I've even seen hats used during water birth, with an attendant placing ...

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Vitamin K

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What is vitamin K?

Vitamin K plays an important part in making our blood clot. If blood can't clot properly, uncontrolled bleeding can happen.

Why does my baby need vitamin K?

All babies are born with low levels of vitamin K. Although these vitamin K stores get used up quickly in the first few days of a baby's life, (NHS 2008) there is usually enough to stop bleeding. However, a very small number of newborn babies, about one in 10,000 babies, have vitamin K deficiency bleeding (VKDB) (NHS 2008). These babies don't have enough vitamin K to make their blood clot.

If your baby has a deficiency of vitamin K, he may spontaneously bruise or bleed. This can happen within the first 12 weeks of birth. Early warning signs are bleeding from the nose or mouth, or bleeding from the umbilical stump or bottom (NICE 2006).

However, some babies who suffer from VKDB do not have these visible early bleeds. Instead, the first bleed may be a serious one into his brain or gut. These bleeds are internal, so it is unlikely that you will be able to tell if your baby has had one. Such bleeds can be life-threatening.

For this reason, doctors recommend that all babies receive vitamin K after birth.

There are three categories of VKBD:

Early VKDB: bleeding in the first 24 hours after birth

Classic VKDB: bleeding in the first week of life

Late VKDB: bleeding when your baby is two weeks to 12 weeks old

(Medline 2012, Tidy 2014)
Late VKDB is very rare, but, it is the most worrying category, as it is the most likely to cause fatalities. If your baby has late VKDB, he is more likely to have internal bleeding, which is harder to detect and can be very serious.
In more than half late-onset cases, babies have a brain haemorrhage. Sadly, a fifth of these babies die (NICE 2006).

Some babies with VKDB do not have any risk factors. But in most cases, VKDB affects breastfed babies who:

were born before 37 weeks of pregnancy

were born by forceps, ventouse or caesarean section

have been bruised during birth

had breathing difficulties at birth

have liver problems or were poorly at birth

whose mums have taken drugs during pregnancy, either for epilepsy, to prevent clots, or for tuberculosis
(NCT 2010, Pereira 2003, NICE 2006)

Breastfed babies with these factors are more vulnerable to VKDB than bottled-fed babies because formula milk is supplemented with vitamin K at higher levels than those naturally found in breastmilk. Eating a diet rich in vitamin K foods will have little or no effect on how much vitamin K there is in your milk (Booth 2008, NCT 2010).
This does not mean that you have to think about formula-feeding instead. Doctors advise that all babies have vitamin K at birth, and this includes formula-fed babies.

Your breastfed baby will get the extra protection he needs from one or more doses of vitamin K. This means that he will get all the benefits of breastfeeding as well as protection from VKDB. Breastfeeding soon after birth and on demand will also help to boost your baby's own vitamin K levels. Your colostrum contains more vitamin K than later breastmilk, and feeding on demand will help to maximise your baby's intake (NCT 2010).

Doctors recommend that your baby has a dose of vitamin K by an injection. This is because it is the most effective and efficient way of protecting babies from VKDB (Sutor 2003). One injection is all your baby needs, and it gives him immediate cover (Busfield et al 2007, NICE 2006). If your baby has risk factors for VKDB, an injection of vitamin K will also be more easily absorbed than oral drops (Pereira 2003).

As with any injection, it can be sore and leave a little bruise, but it'll only take a few seconds.

If you decide to opt for the vitamin K drops instead, you need to make sure that your baby gets all of the doses. Studies on giving vitamin K by mouth have found that missed doses can leave babies vulnerable to late-onset VKDB (NICE 2006, Wariyar et al 2000). It can be easy to forget about the right number of doses when you are going through the first hectic weeks of being a new parent.

The number of drops your baby needs depends on whether he is breastfed or formula-fed. Your baby will need:

Three doses of vitamin K by mouth, if your baby is breastfed. Two doses are given during his first week of life, and another dose is given when he is one month old.

If your baby is bottle-fed, you can opt for two doses of vitamin K by mouth during his first week of life.
(NICE 2006, Van Winckel 2009)

Busy maternity units may sometimes miss giving your baby vitamin K drops or an injection. Make sure you or your partner check with your midwife before you leave hospital that your baby has received the correct dose of vitamin K.
What if I don't want my baby to have vitamin K?

Doctors strongly recommend that your baby is given vitamin K. Although VKDB is rare, it is very serious and can be fatal.

There is no strong evidence that vitamin K is harmful, but there is good evidence that vitamin K given by injection or by mouth can help prevent VKDB and improve blood clotting in newborns (NICE 2006, Puckett 2009). The administration of vitamin K to newborns has meant that there are now very few cases of VKDB in the UK (Tidy 2014).

It is also worth bearing in mind that not all babies who get VKDB have any of the risk factors, which could leave your baby open to risk if he does not have vitamin K. An injection of vitamin K is therefore recommended for all babies, not just the ones who are at risk of developing VKDB.

However, if you really don't want your baby to have vitamin K, you don't have to allow it. But before you decide, talk to your midwife or doctor about vitamin K. Ask their opinion and if they have any leaflets that you can read.

Whether or not you decide to give vitamin K to your baby, and how, make sure that you report any unexplained bleeding to your doctor or midwife immediately.

Last reviewed: February 2014

References

Booth S, Al Rajabi A. 2008. Determinants of vitamin K status in humans. Vitamins and hormones. 78:1-22 www.ncbi.nlm.nih.gov [Accessed February 2014]

Busfield A, McNinch A, Tripp J. 2007. Neonatal vitamin K prophylaxis in Great Britain and Ireland: the impact of perceived risk and product licensing on effectiveness. Archives of Disease in Childhood 92:754-8

NCT 2010. Vitamin K. www.nct.org.uk [pdf file, accessed January 2014]

NHS. 2008. Vitamin K and vitamin KJ deficiency bleeding in the newborn. www.royalfree.nhs.uk [pdf file, accessed January 2014]

NICE. 2006. Routine postnatal care of women and their babies. National Institute of Health and Clinical Excellence. www.nice.org.uk [pdf file, accessed January 2014]

Fear NT, Roman E, Ansell P, et al. 2003. Vitamin K and childhood cancer: a report from the United Kingdom Childhood Cancer Study. British Journal of Cancer 89(7):1228-31

Pereira S, Shearer M et al. 2003. Intestinal absorption of mixed micellar phylloquinone (vitamin K) is unreliable in infants with conjugated hyperbilirubinaemia: implications for oral prophylaxis of vitamin K deficiency bleeding. Archives of Disease in Childhood: Fetal and Neonatal Edition. 88(2):113-8

Puckett RM and Offringa M. 2009. Prophylactic vitamin K for vitamin K deficiency bleeding in neonates. Cochrane Database of Systematic Reviews Issue 4. Art. No. CD002776. onlinelibrary.wiley.com [Accessed January 2014]

Ross JA and Davies SM. 2000. Vitamin K prophylaxis and childhood cancer. Med Pediatr Oncol 34:434-7

Sutor A. 2003. New aspects of vitamin K prophylaxis. Seminars in thrombosis and nemostasis. 29(4):373-6

Tidy C. 2014. Vitamin K deficiency bleeding. Patient.co.uk www.patient.co.uk [Accessed February 2014]

Van Winckel M, De Bruyne R et al. 2009. Vitamin K: an update for the paediatrician. European Journal of Paediatricians. 168(2):127-34

Wariyar U, Hilton S, Pagan J, et al. 2000. Six years' experience of prophylactic oral vitamin K. Archives of Disease in Childhood Fetal & Neonatal Edition 82(1):F64-8

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Vitamin K plays an important part in making our blood clot. If blood can't clot properly, uncontrolled bleeding can happen. All babies are born with low levels of vitamin K. Although these vitamin K stores get used up quickly in the first few days of a baby's life, (NHS 2008) there is usually enough to stop bleeding.

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Delayed Cord Clamping

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Vitamin K and newborns: what you need to know | Labour & birth articles & support | NCT

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If you’ve heard people talk about Vitamin K but are feeling a bit clueless, here’s the information you’ll need.

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Newborn Baby Tests

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istock.com / Lisa Eastman

In the hours, days and weeks after he is born, your baby will have several routine tests and examinations to check that he is healthy and that all is well. Here's an outline of what to expect and what your midwife and doctor will be looking for when they carry out the tests.

The number of tests and examinations may seem alarming, but don't worry. All babies, born in hospital, at a birth centre, or at home, will be having the same checks.

What are the first tests my baby will have?

Your baby will have a few checks and examinations in the first hours of his life. The first is the Apgar score, which your midwife will record at one minute, then again at five minutes, after your baby's born (NICE 2014).

Your midwife can do this test by watching your baby's colour, breathing, behaviour, activity and posture. This will tell her whether your baby has any immediate problems that need medical support (NICE 2014).

Most babies are fine, or may just need to be watched for a while. If your baby does need some help, your midwife may give him some air or clear out his airways to help him breathe (NICE 2014).

About an hour after the birth, after you've had a cuddle with your baby and, ideally, some skin-to-skin contact, your midwife will also:

weigh your baby

check his temperature

measure the circumference of his head (NICE 2014)

These measurements will later be added to his developmental charts in his red book (personal child health record). Your health visitor will give you your baby's red book shortly before or after your baby is born.
During this time a doctor or midwife will also offer to give your baby a dose of vitamin K to protect him from vitamin K deficiency bleeding (VKDB) (NHS 2018a).

What is the newborn examination?

The newborn examination is a full physical check of your baby for any problems or conditions. A health professional will offer to examine your baby within 72 hours of his birth (NHS 2018c, NICE 2015). This gives your baby time to adjust to the outside world and means he can get treatment quickly in the unlikely event that any problems are found.

If your baby was born in a hospital or birth centre, a midwife or paediatrician will usually examine your baby before you both go home. If you had a home birth, your midwife or GP may carry out the newborn examination.

The examination will be done while you, and ideally your partner, are present, so you'll be able to ask questions as it happens (NHS 2018c, NICE 2015). The health professional doing the exam may ask you questions about your family's medical history. So now's the time to mention any childhood medical conditions in your or your partner's family, such as eczema or asthma.

Your midwife or doctor will check your baby from head to toe, so your baby will need to be undressed for part of the examination (NHS 2018c).

Head

The doctor or midwife will look at the shape and size of your baby's head (NHS 2018c, NICE 2015). A squashed or moulded head is a common feature in newborns. If you had a vaginal birth, the gentle pressure that happens when your baby is squeezed through the birth canal may have resulted in your baby's head becoming misshapen.

Your baby's head can mould in this way because there are soft spots, called fontanelles, between the bones in his skull. This will even out as the soft spots close, and the bones in his head meet and fuse. Your doctor or midwife will check these soft spots.

If your baby needed help to be born with ventouse or forceps, there's a small risk of bruises appearing on his head or skull bone (cephalhaematoma). These will soon disappear, but ask your midwife if you're worried about them (NHS 2018a).

Ears and eyes

Your midwife will have already looked at your baby's eyes to check for any obvious problems at birth. During the newborn physical examination, your doctor or midwife will shine a light from an ophthalmoscope in your baby's eyes to check they have something called a red reflex (NHS 2018f). This looks similar to the red eye effect from a camera flash. Checking that your baby has this reflex helps your doctor or midwife to rule out certain eye conditions, such as cataracts (NHS 2018f).

Your GP will also examine your baby's eyes when he is between six weeks and eight weeks old. This may be combined with your postnatal check (NHS 2016b).

If you are worried about your baby's sight at any time, mention it to your doctor or health visitor.

Get tips on how to monitor your baby's eyesight as he grows.

Mouth

Your doctor or midwife will put a finger in your baby's mouth to check that the roof of his mouth (palate) is complete and his sucking reflex is working (Tidy 2016a). A gap in the palate, called cleft palate, will need surgery and may make feeding difficult.

Learn more about what support you will receive if your baby is diagnosed with a cleft palate.

Your doctor or midwife may also check your baby's tongue for tongue-tie. This happens when his tongue remains more anchored to the bottom of his mouth than it should be, restricting movement. It may only be checked for if your baby has persistent problems latching on to breastfeed (NICE 2015).

Read how tongue-tie can affect your baby's feeding and how it can be treated.

Heart

Your doctor or midwife will listen to your baby's heart with a stethoscope. This will help her to identify any potential heart problems, and to check if your baby has a heart murmur (an extra or unusual sound made by the heart) (PHE 2017, Tidy 2016a).

Try not to worry if your midwife or doctor detects a heart murmur. These are common in newborns, and may be caused by how your baby's heart adapts to the world outside your womb (PHE 2014). The vast majority of babies with heart murmurs have no heart problems (Archer 2015). But your doctor or midwife may arrange for a follow-up check to be carried out in six weeks to eight weeks' time (Roy et al 2017).

Your midwife or doctor will also feel for a pulse in your baby's groin (the femoral pulse) to check for any heart defects. Some hospitals also offer to test how much oxygen is in your baby's blood (oxygen saturation levels). Your doctor or midwife will carry out this test by placing a probe on your baby's fingers and toes.

Lungs

Your doctor or midwife will listen to your baby's breathing with a stethoscope and make sure both of his lungs are working properly (Tidy 2016a).

Genitals

Baby genitals are often swollen and dark-coloured in the first few days. This is nothing to worry about. It may be down to a surge of hormones, passed from you to your baby before he was born. Or it may be a build-up of extra fluid in his body, which is common in babies.

For boys, the scrotum is checked for undescended testicles (NHS 2018c, PHE 2017).

If your baby has an undescended testicle it's likely the testicle will come down on its own before he's six months. For this reason, doctors usually wait to start any treatment. However, if your baby's testicle has not descended by six months, your doctor is likely to recommend surgery to move the testicle down (NHS 2018c, PHE 2017).

Your baby's penis will also be checked to ensure the opening is at the tip of the penis, and not on the underside.

The doctor or midwife will check your baby's bottom to ensure the opening to his back passage is normal. They will probably ask if your baby has had a wee or passed a dark-coloured poo (meconium) (NICE 2014, Tidy 2016a).

Skin

Your baby's skin will be checked for birthmarks (Tidy 2016a), including:

stork marks: reddish or purple V-shaped marks that can appear on your baby's eyelids, in the middle of his forehead or at the back of his neck.

blue spots (congenital dermal melanocytosis): a bluish patch of darker pigment, most commonly over the lower back or bottom. They used to be known as Mongolian blue spots and you may still hear them called by this name.

strawberry marks: raised red areas

Most birthmarks are completely harmless, and will fade during childhood. Ask your doctor for advice if you are worried.
Hands and feet

The doctor or midwife will check your baby's arms, hands, legs and feet. His fingers and toes will be counted and checked for webbing.

Your baby's palms will be checked to see if two creases, called palmar creases, run across them. About four per cent of the population have just one palmar crease on one hand and it's even rarer to have one line on both hands (Sharma and Sharma 2011).

Single palmar creases are sometimes associated with Down's syndrome (Tidy 2016a). But in the unlikely event of your baby having Down's syndrome, there would be other clear physical signs (Tidy 2016b).

The doctor or midwife will look at your baby's feet and ankles. This is to check for talipes (clubfoot), where the front half of the foot turns in and down. You may already know your baby has talipes if it was shown on an ultrasound scan.

Get the facts on talipes and how it can be treated.

Spine

Your doctor or midwife will look at how straight your baby's spine is. It is quite common for babies to have a tiny dimple at the base of the spine, called a sacral dimple (Tidy 2016a). In most cases this will cause no problems. Occasionally, a deep sacral dimple may indicate a problem with your baby's nerves in his lower spinal cord.

If your baby has a deep sacral dimple, he will be checked for other nerve problem symptoms such as leg weakness, cold and bluish soles of feet, and difficulties pooing and weeing.

Hips

Your doctor or midwife will gently move your baby's hips to check how stable the joints are (PHE 2017, Tidy 2016a). She will open his legs wide, and then bend and unbend them. If your doctor or midwife finds any instability, she will carry out further tests to check for hip problems.

Reflexes

Your newborn baby has several reflexes such as sucking, rooting and grasping. Your doctor or midwife will check these by safely encouraging your baby to show his reflexes (PHE 2017).

The most commonly tested reflex during the examination is the Moro reflex (also called the startle reflex). Your baby's head is allowed to gently and safely fall for a short distance. He'll respond by flinging out both arms with his fingers spread and legs outstretched. He may also cry a little. Rest assured your baby will be fine, and his responses are simply showing that all is well.

Jaundice check

Your doctor or midwife will examine your baby for signs of jaundice. This is a common condition that causes a yellowish tinge on babies' skin. Most cases will clear up on their own within 10 to 14 days, but if tests show your baby has a lot of bilirubin (the substance that causes jaundice) in his blood, he may be given light treatment (phototherapy) to reduce it (NHS 2015).

There are different levels of treatment, depending on how jaundiced your baby is. Read our article on jaundice for more information.

Bear in mind that screening tests may not pick up every problem. But if your baby does have a problem that's picked up during the newborn examination, there are many benefits to having this identified early on. Your doctor or midwife should give you information about the suspected problem and answer any questions you may have.

You should also be offered advice about where to find more information and support. Your doctor or midwife will let you know straight away if she has any concerns and will advise you on what is likely to happen next. Your baby may need further tests or he may be referred directly for specialist treatment.

What other tests will my baby have in the first six weeks?
Hearing test
Your baby may have a hearing test shortly after birth, either in hospital, a community clinic, or at home (NHS 2018b, PHE 2017). It's called an automated otoacoustic emission (AOAE) test. It only takes a few minutes and doesn't hurt your baby.

If the test doesn't show a clear result, you may be asked to come back for another test. This doesn't necessarily mean that there's a problem. Your baby may have been unsettled when the test was first carried out, or there may be fluid or a temporary blockage in his ear. Or there may have been background noise during the screening (NHS 2018b).

Find out more about what happens during the second hearing test in our article on baby hearing.

Heel-prick test

The next routine test your baby will have is a heel-prick test. This will be carried out around five days to eight days after the birth, usually at home (PHE 2017). Your midwife will carry out this test. She'll take a tiny amount of blood from your baby's heel.

This blood sample will be tested for the following conditions. These conditions are rare and early detection will give your baby the best chance of successful treatment:

An inherited condition called phenylketonuria (PKU), which affects the way proteins are metabolised.

Cystic fibrosis, which affects the lungs and digestive system.

MCADD, a condition that affects the way the body converts fat into energy.

Sickle cell disease, a genetic blood disorder.

Thyroid deficiency.

Homocystinuria, an inherited metabolic disorder.

Maple syrup urine disease, glutaric aciduria type 1, and isovaleric acidaemia, which are all inherited disorders in which the body is unable to process certain protein building (amino acids) (NHS 2018e, PHE 2014).

Your baby may cry a little when the blood is taken, but he will recover very quickly with a cuddle.
You will get the results of the heel-prick test by the time your baby is eight weeks old. You will either get a letter or a health professional will contact you. In the unlikely event that your baby has any of these conditions he will be referred to a specialist who can carry out further investigations and plan his treatment.

Ten to 14-day review

Your health visitor will visit you at home 10 to 14 days after the birth. She will carry out a top-to-toe check of your baby, and ask you about your own physical and emotional health (NHS 2016a).

This is the perfect time to discuss any issues you may have been having since the birth. If you don't already have it, she will also give you your baby's red book (personal child health record).

Healthcare after the birth
Six to eight week check
The next screening test you and your baby will have will be at six to eight weeks, and may be combined with your postnatal check with your doctor (NHS 2016b).

If you have any concerns about your baby before then, don't hesitate to call your midwife, health visitor or doctor. Your midwife will also give you information on signs and symptoms to look out for in your newborn and who to contact for help.

When your baby's eight weeks old, you'll also be offered the first set of immunisations to protect him against common infectious diseases. Find out what they protect against in our immunisations chart.

References

Archer. 2015. Heart murmur in children. DynaMed Plus. www.dynamed.com [Accessed October 2018]

iHV. 2017. Why a health visitor? Institute of Health Visiting. https://ihv.org.uk/ [Accessed June 2018]

NHS. 2015. Newborn jaundice. NHS Choices, Health A-Z. www.nhs.uk [Accessed June 2018]

NHS. 2016a. Services and support for parents. NHS Choices, Health A-Z. www.nhs.uk [Accessed July 2018]

NHS. 2016b. Your six-week postnatal check. NHS Choices, Health A-Z. www.nhs.uk [Accessed December 2018]

NHS. 2017. Getting to know your newborn. NHS Choices, Health A-Z. www.nhs.uk [Accessed April 2018]

NHS. 2018b.Newborn hearing screening. NHS Choices, Health A-Z. www.nhs.uk [Accessed April 2018]

NHS. 2018c.Newborn physical examination. NHS Choices, Health A-Z. www.nhs.uk [Accessed April 2018]

NHS 2018d.Undescended testicles. NHS Choices, Health A-Z. www.nhs.uk [Accessed October 2018]NHS. 2018e. Newborn blood spot test. NHS Choices, Health A-Z. www.nhs.uk [Accessed April 2018]

NHS. 2018f.Eye tests for children. NHS Choices, Health A-Z. www.nhs.uk [Accessed September 2018]

NICE. 2014.Intrapartum care for healthy women and babies. Last updated February 2017. National Institute for Health and Care Excellence, Clinical guideline 190. www.nice.org.uk [Accessed April 2018]

NICE. 2015.Postnatal care up to 8 weeks after birth. Last updated February 2015. National Institute for Health and Care Excellence, Clinical guideline, 37. www.nice.org.uk [Accessed April 2018]

PHE 2017.Screening tests for you and your baby. Public Health England. www.gov.uk/government/organisations/public-health-england [Accessed April 2018]

Roy R, Clarke P, Daniels R, et al. 2017.Heart murmurs: information for parents/carers. Jenny Lind Children's Hospital, Norfolk and Norwich University Hospitals. www.nnuh.nhs.uk [Accessed December 2018]

Sharma DK, Sharma V. 2011. Prevalences of Simian, Sydney and Suwon creases and their association with each other, body sides, handedness, sex and anomalies/diseases/syndromes in a population of central India.Int J Morphol 29(3):1069-75

Tidy C. 2016a.Neonatal examination. Patient.Info. https://patient.info [Accessed April 2018]

Tidy C. 2016b.Down's syndrome. Patient.Info. https://patient.info [Accessed April 2018]

# data[].attributes.attachment_link.description
istock.com / Lisa Eastman In the hours, days and weeks after he is born, your baby will have several routine tests and examinations to check that he is healthy and that all is well. Here's an outline of what to expect and what your midwife and doctor will be looking for when they carry out the tests.