Third stage of labour: delivering placenta and cord clamping

What is the third stage of labour?

The third stage of labour is the time between when you have your baby and when the placenta (or afterbirth) comes out (Begley et al, 2011; NICE, 2017).

Once your baby’s born, the release of the hormone oxytocin will make the uterus contract and become smaller. This’ll make the placenta start to separate.

You will have some bleeding during the third stage of labour as you pass the placenta (Begley et al, 2011).

Active management versus physiological management

Generally, you have two options for how you do the third stage of labour: active management and physiological management. But there’s also a third option – mixed management – combining active and physiological approaches (Begley et al, 2011; NICE, 2017).

Physiological management:

• It’s generally practised in midwife-led units and in home births.
• It allows the placenta to be ready to come out mainly by pushing, gravity, contractions and sometimes by nipple stimulation.
• It doesn’t use oxytocin injections.
• The umbilical cord is clamped and cut once it has stopped pulsing or when the placenta has come out.
• It can take up to one hour (and shouldn’t take more).
• Skin-to-skin contact and breastfeeding can help it along, by making your body produce more oxytocin.
• It involves sitting in an upright position to encourage the placenta to come out.
• Your midwife will monitor your blood loss and keep you and your baby warm.
• You’ll push the placenta out once it has separated and moved down to your vagina.
• It’s mostly used if you’re at low risk of heavy blood loss.
• You can change to active management at any time if needed. (Begley et al, 2011; NICE, 2017)

When the placenta is out, your midwife will clamp and cut the cord. But if you want, you can ask them to wait until it has finished pulsating (RCM, 2013a). Delaying cord clamping for at least a minute has been shown to be beneficial for babies(Science Direct, 2021).

Active management:

• Involves an injection of a drug called syntocinon or ergometrine in your thigh soon after your baby’s born.
• It speeds up the delivery of the placenta – it usually happens within 30 minutes of having your baby. Your midwife will apply some pressure to your belly and pull gently on the umbilical cord to ease the placenta out.
• You’ll have the umbilical cord cut between one and five minutes after you give birth.
• It lowers the risk of heavy blood loss.
• It might make you feel sick or vomit, and can increase your risk of high blood pressure.

 (Begley et al, 2011; RCM 2013b; NICE, 2017)

Should I have active management or physiological management?

Generally, active management is recommended for all women, to avoid severe haemorrhage. Though this is more of an issue in low-income countries where women are more likely to be poorly nourished, anaemic or have infectious diseases (Begley et al 2015).

If you do go through a haemorrhage though, you’ll need to be transferred to a hospital if you’re not already there. You’ll then be offered treatment that involves:

If the bleeding continues, you’ll be given more oxytocin, ergometrine or other drugs. In some cases, an examination under anaesthesia and surgery and/or a blood transfusion might be needed (NICE, 2017).

Retained placenta and problems after birth

If all or some of your placenta has not come out within one hour of you having your baby, this is called a retained placenta.

If that happens to you, you’ll need to be put on an intravenous drip. You might also be offered a vaginal examination to see whether you need an operation to remove the placenta. You’ll also be offered pain relief (NICE, 2017).

If you do have the placenta removed under anaesthesia, you’ll need to have it done within a few hours of the birth to avoid haemorrhage (Weeks, 2001). You’ll then need to be transferred to an obstetric unit if you are not already there and might be advised to have an epidural or spinal anaesthetic when the placenta is actually removed (NICE, 2017).

This page was last reviewed in July 2018.

Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

We also offer antenatal courses which are a great way to find out more about birth, labour and life with a new baby.

Important information on the third stage of labour can be found in NICE guidelines.