Third Stage of Labour

Background: Detachment of the placenta occurs in about 96% of patients within 30 minutes of completion of the second stage of labour, thus any further delay there after is usually considered as retained placenta. It is associated with the risk of post-partum haemorrhage and anaemia. Objectives: To determine the incidence, risk factors, clinical presentation and complications of retained placenta at the study centre during the period under review. Methods: This was a retrospective case-control study in which records of women with retained placenta between January 2011 and December 2015 were retrieved and analysed for their age, parity, risk factors, clinical presentation and associated complications and compared with equal number of patients without retained placenta. Results: There were 11 cases of retained placenta recorded among the total number of 2068 deliveries during the study period, giving an incidence of 0.53% retained placenta in this study. Majority of cases (45.4%) were between age 30 and 39 years which was similar to the controls (54.5%). Most of the cases were unbooked (81%). Similarly, most women in both cases (82%) and controls (73%) were multiparae. All the 5 cases (45.5%) that had post-partum haemorrhage received blood transfusion. The overall incidence of post-partum anaemia was 54%. The average weights of the placentae were significantly smaller in the cases with placental retention (p = 0.010). Conclusion: Retained placenta is associated with significant risks of post-partum haemorrhage and blood transfusion. Non-booking for antenatal care is the commonest risk factor identified for retained placenta in this study.

for her continuous support in the development of this handbook; to the staff in CUMH for their invaluable assistance and to Norma Deasy Information and Communications Manager, Communications Department HSE for her skilful editorial and publishing guidance. Thanks also to Olive Long, Acting Director of Midwifery CUMH, for her support, to Edel Nagle, Clinical Midwife Manager 3 for permitting us to use some information from the CUMH annual maternity magazine, to Rhonda Cullinane for providing administrative support, to Ethel Burns, RM, Oxford University Hospitals NHS Trust, UK for permission to use their leaflet on perineal massage and Queensland Health, Australia for permission to use their baby feeding cues graphic. I am also very grateful to the midwives and parents along with Sandra Eaton, HSE National Communications Division, who reviewed the final draft of the booklet and provided very helpful comments for its completion. Finally, I wish to thank Carmel Buckley, and her team in the Nursing and Midwifery Planning and Development Unit (NMPDU) for funding this handbook and for their support. Our vision is to empower parents to develop the skills to negotiate all aspects of their journey through pregnancy, labour, birth and early parenthood. Day 1: 9.30am to 12 noon and repeated from 2pm to 4.30pm Presented by a midwife. (Includes a break)

Background The EUropean Project on obstetric Haemorrhage Reduction: Attitudes, Trial, and Early warning System (EUPHRATES) is a set of five linked projects, the first component of which was a survey of policies for management of the third stage of labour and immediate management of postpartum haemorrhage following vaginal birth in Europe. Objectives The objectives were to ascertain and compare policies for management of the third stage of labour and immediate management of postpartum haemorrhage in maternity units in Europe following vaginal birth. Design Survey of policies. Setting The project was a European collaboration, with participants in 14 European countries. Sample All maternity units in 12 countries and in selected regions of two countries in Europe. Methods A postal questionnaire was sent to all or a defined sample of maternity units in each participating country. Main outcome measures Stated policies for management of the third stage of labour and the immediate management of postpartum haemorrhage. Results Policies of using uterotonics for the management of the third stage were widespread, but policies about agents, timing, clamping and cutting the umbilical cord and the use of controlled cord traction differed widely. For immediate management of postpartum haemorrhage, policies of massaging the uterus were widespread. Policies of catheterising the bladder, bimanual compression and in the choice of drugs administered were much more variable. Conclusions Considerable variations were observed between and within countries in policies for management of the third stage of labour. Variations were observed, but to a lesser extent, in policies for the immediate management of postpartum haemorrhage after vaginal birth. In both cases, policies about the pharmacological agents to be used varied widely.

Contributing factor to uterus contraction mechanism is the imbalance of the extracellular calcium level. When extracellular calcium level is inadequate, response of the myometrium to oxytocin decreased and the calcium influx inter-cell membranes are suppressed, thus inhibit uterine contractions. The aim of this research is to know the correlation between levels of calcium and the strength of uterine contraction in the active phase of first stage labor. This was a cross-sectional analytic correlative study in the Dr. Rasidin Hospital Padang and UPTD Health Laboratory in West Sumatra province, in was conducted from November 1st, 2014 till February 2016. Sampling was takes by using non probability sampling with consecutive sampling. Subjects of this research were the active phase of first stage labor of 62 people. Kolmogorof Smirnov normality test was used to the normality of the data. Pearson correlation test was conducted to examine the correlation between dependent and independent v...

It seems that we are constantly being asked to reconsider and redefine ourselves and our practice. It doesn't help that most of us are employed by a service that is subject regularly to the vagaries of political change, both locally and nationally, and we have to compete for priority with other disciplines. Recently, most of the change we have experienced has been institutional, and for many of us it has been both exhilarating and painful. Perhaps the time has come for us to rest from the disruption of organizational change, and reflect on our practice. Maybe, within that space, we can take charge of future developments, both on our behalf, and for the women we support.

Literature on the use of plasma cortisol to quantify psychophysiological stress in humans is extensive. However, in parturition at term gestation, the use of cortisol as a biomarker of stress is particularly complex. Plasma cortisol levels increase as labor progresses. This increase seems to be important for maintenance of maternal/fetal well-being and facilitation of normal labor progress. Unique physiological and methodological issues involved in the use of cortisol as a biomarker of stress in labor present challenges for researchers. This review examines these issues, suggests mixed methods and within-subject repeated measures designs, and offers recommendations for assay procedures for parturient sampling. Documentation of clinical interventions and delivery outcomes may elucidate relationships among psychophysiological stressors, cortisol, and normal labor progress. With attention to these methodological issues, analysis of plasma cortisol may lead to clinical interventions tha...

The importance of optimising maternal/baby psychophysiology has been integrated into contemporary midwifery theories but not in the detail required to really understand the underpinning biological basis. The functioning of the autonomic nervous system, as it relates to the uterus is reviewed. The physiology of myometrial cell contraction and relaxation is outlined. The main focus is on the factors that affect the availability and uptake of oxytocin and adrenaline/noradrenaline in the myometrial cells. These are the two key neuro-hormones, active in the 3rd and 4th stages of labour, that affect uterine contraction and retraction and therefore determine whether the woman will have an atonic PPH or not. The discussion explains and predicts the physiological functioning of the uterus during the 3rd and 4th stages of labour when skin-to-skin contact and breastfeeding occurs and when it does not. This biologically based theory hypothesises that to achieve and maintain eutony and eulochia,...

Background Psychological aspects of labor and birth have received little attention within maternity care service planning or clinical practice. The aim of this paper is to propose a model demonstrating how neurohormonal processes, in particular oxytocinergic mechanisms, not only control the physiological aspects of labor and birth, but also contribute to the subjective psychological experiences of birth. In addition, sensory information from the uterus as well as the external environment might influence these neurohormonal processes thereby influencing the progress of labor and the experience of birth. Methodology In this new model of childbirth, we integrated the findings from two previous systematic reviews, one on maternal plasma levels of oxytocin during physiological childbirth and one meta-synthesis of women´s subjective experiences of physiological childbirth. Findings The neurobiological processes induced by the release of endogenous oxytocin during birth influence maternal behaviour and feelings in connection with birth in order to facilitate birth. The psychological experiences during birth may promote an optimal transition to motherhood. The spontaneous altered state of consciousness, that some women experience, may well be a hallmark of physiological childbirth in humans. The data also highlights the crucial

Background Psychological aspects of labor and birth have received little attention within maternity care service planning or clinical practice. The aim of this paper is to propose a model demonstrating how neurohormonal processes, in particular oxytocinergic mechanisms, not only control the physiological aspects of labor and birth, but also contribute to the subjective psychological experiences of birth. In addition, sensory information from the uterus as well as the external environment might influence these neurohormonal processes thereby influencing the progress of labor and the experience of birth. Methodology In this new model of childbirth, we integrated the findings from two previous systematic reviews, one on maternal plasma levels of oxytocin during physiological childbirth and one meta-synthesis of women´s subjective experiences of physiological childbirth. Findings The neurobiological processes induced by the release of endogenous oxytocin during birth influence maternal behaviour and feelings in connection with birth in order to facilitate birth. The psychological experiences during birth may promote an optimal transition to motherhood. The spontaneous altered state of consciousness, that some women experience, may well be a hallmark of physiological childbirth in humans. The data also highlights the crucial

Introduction: Studies have shown that long-term positive behavioural and physiological changes are induced in connection with vaginal, physiological birth, and skin-to-skin contact after birth in mothers and babies. Some of these effects are consistent with the effect profile of oxytocin. This scoping review explores whether epigenetic changes of the oxytocin gene and of the oxytocin receptor gene (OTR) are involved in these effects. Methods: We searched Pubmed, Medline, BioMed Central, Cochrane Library, OVID, and Web of Science for evidence of epigenetic changes in connection with childbirth in humans, with a particular focus on the oxytocin system. Results: There were no published studies identified that were related to epigenetic changes of oxytocin and its receptor in connection with labour, birth, and skin-to-skin contact after birth in mothers and babies. However, some studies were identified that showed polymorphisms of the oxytocin receptor influenced the progress of labour....

Labour has become the domain of hospital medical culture, and we have very little space and time within our current maternity service to watch and wait. This creates an alien environment for birth to unfold naturally. Labour is a primal event, and the woman's body often knows what it is doing even if she herself is unsure.

During the last decade the process of childbirth has undergone many changes in South Africa. Most women currently give birth in the hospital under the supervision of a medical practitioner because they belong to a medical aid scheme which enables them to consult an obstetrician for their delivery. Due to this fact, a large number of deliveries take place in a hospital setting, be it private or provincial. Research undertaken in South Africa (Du Plessis, 1991:58) with regard to women's experience of childbirth in a hospital while under the care of a medical practitioner; found that they were dissatisfied with their birthing experience and felt disempowered. They felt a loss of control during the labour process, experienced a sense of abandonment and lack of involvement. Different modern approaches to childbirth have developed all over the world, essentially in response to the progressive medicalisation of birth with an increase in the number of home deliveries by a midwife (Robertson, 1988:2). In South Africa, there seems to be an increase in the demand by mothers for a less technological medicalised birthing experience. There is furthermore an increase in the number of women who are beginning to express a preference for deliveries with a private midwife. In South Africa the trend back towards delivering with a private midwife is relatively recent and the field of private practising (independent) midwives a growing one. Research pertaining to this topic has been carried out in the United States of America, the United Kingdom and the Netherlands which concluded that the mother's experience of the birthing process with a midwife was a superior one. The experiences of the mother who delivered with a private midwife is an area in South Africa where very little documented research has been carried out. Due to this fact minimal documented research is available. Statistics with regard to the number of babies delivered by private midwives are unknown and no register exists of the names and numbers of private midwives available. The purpose of this research study was to explore and describe the experiences of women related to their exposure of birthing with a private midwife. This allows recommendations to be made with regard to the practice of private midwifery in South Africa. The private midwives can use these guidelines to improve their practice and contribute to a better birthing experience. A qualitative, descriptive, explorative and contextual research design was utilised to conduct this research. The focus was to obtain information that would facilitate understanding of the women's experiences of labor while under the care of a private midwife in a midwife obstetric unit. A qualitative design was used where the phenomenological method was employed. Purposeful, convenient sampling was done where the researcher consciously selected certain subjects from a midwife obstetric unit in Gauteng. The collection and analysis of data involved exploring and describing the women's birthing experiences by means of analysis of naïve sketches collected prior to discharge; unstructured in-depth interviews and a focus group. These interviews were transcribed verbatim to add depth to the findings. Tesch's descriptive method was used to analyse data. Data were clustered into relevant themes. A thorough literature study was performed in order to try and describe the phenomena as seen by others. Books relating to the research topic, relevant research material and newspaper articles were utilised. Guidelines were discussed and formulated. Lincoln and Guba's measures to ensure trustworthiness were applied. Two main themes were extracted. They were that a therapeutic relationship developed with the midwife, but at the same time they had unrealistic expectations with regard to the birthing process. These two themes were further divided into subthemes which will be discussed with regards to the research findings and will be verified by means of a literature control. All information will be supported by direct quotes obtained from the data collected during the interviews. The researcher found that women who delivered with a private midwife found it to be a hugely

In this article, I present the concept of ‘birthing consciousness,’ a psycho-physical altered state of women that can occur during natural and undisturbed birth. I demonstrate that this altered state of consciousness (ASC) has phenomenological and cognitive features of hypofrontality; thus, birthing consciousness probably shares a similar brain mechanism to that postulated by the transient hypofrontality theory (THT). I argue that until recently (with the advent of modern medical intervention), in evolutionary terms, women lacking the proclivity for this specific brain mechanism had a lower chance of reproducing successfully. Hence, I suggest a general and preliminary hypothesis concerning THT: Birthing consciousness is one example of an adaptive pain-induced ASC associated with transient hypofrontality.

Labour has become the domain of hospital medical culture, and we have very little space and time within our current maternity service to watch and wait. This creates an alien environment for birth to unfold naturally. Labour is a primal event, and the woman's body often knows what it is doing even if she herself is unsure.

The birth environment continues to be a subject of midwifery discourse within theory and practice. This article discusses the birth environment from the perspective of understanding the aromas and aromatherapy for the benefit of women and midwives The dynamic between the olfactory system and stimulation of normal birth processes proves to be fascinating. By examining other health models of care we can incorporate simple but powerful methods that can shape clinical outcomes. There is still more that midwives can do by using aromatherapy in the context of a multisensory approach to make birth environments synchronise with women's potential to birth in a positive way.

Background: The importance of optimising maternal/baby psychophysiology has been integrated into contemporary midwifery theories but not in the detail required to really understand the underpinning biological basis. Method: The functioning of the autonomic nervous system, as it relates to the uterus is reviewed. The physiology of myometrial cell contraction and relaxation is outlined. The main focus is on the factors that affect the availability and uptake of oxytocin and adrenaline/noradrenaline in the myometrial cells. These are the two key neuro-hormones, active in the 3rd and 4th stages of labour, that affect uterine contraction and retraction and therefore determine whether the woman will have an atonic PPH or not. Discussion: The discussion explains and predicts the physiological functioning of the uterus during the 3rd and 4th stages of labour when skin-to-skin contact and breastfeeding occurs and when it does not. Conclusion: This biologically based theory hypothesises that to achieve and maintain eutony and eulochia, midwives and birthing women should ensure early, prolonged and undisturbed skin-to-skin contact for mother and baby at birth including easy access for spontaneous breastfeeding.

NICE guidelines (2007) state that active management for the third stage of labour should be recommended preferentially to physiological management. If these guidelines are followed inflexibly by midwives, they may be in danger of not providing the women in their care with informed choice. This essay explores the ways in which midwives can deliver safe care whilst advocating for their clients' wishes.

The discursive construction of the human placenta varies greatly between hospital and home-birthing contexts. The former, driven by medicolegal discourse, defines the placenta as clinical waste. Within this framework, the placenta is as much of an afterthought as it is considered the "afterbirth." In home-birth practices, the placenta is constructed as a "special" and meaningful element of the childbirth experience. I demonstrate this using 51 in-depth interviews with women who were pregnant and planning home births in Australia or had recently had home births in Australia. Analysis of these interviews indicates that the discursive shift taking place in home-birth practices from the medicalized model translates into a richer understanding and appreciation of the placenta as a spiritual component of the childbirth experience. The practices discussed in this article include the burial of the placenta beneath a specifically chosen plant, consuming the placenta, and having a lotus birth, which refers to not cutting the umbilical cord after the birth of the child but allowing it to dry naturally and break of its own accord. By shifting focus away from the medicalized frames of reference in relation to the third stage of labor, the home-birthing women in this study have used the placenta in various rituals and ceremonies to spiritualize an aspect of birth that is usually overlooked.

This paper presents a physiologically based theory that describes, explains and predicts the mechanisms by which skin-to-skin contact and breastfeeding at birth may reduce the incidence of PPH (Key terms are defined in table 1).  The ideas for this theory have their roots in the practice, wide reading and writing of three authors of this paper.  The overall focus of this paper is on the neuro-hormonal control of the myometrium, including the regulation of uterine contraction and retraction that is essential to minimise blood loss in the 3rd and 4th stages of labour.  First, the background literature concerning the importance of the 3rd and 4th stages of labour is presented. Next, the structure and function of the myometrium is summarised.  Then, the functioning of the autonomic nervous system, as it relates to the uterus is described. Attention is then narrowed to the key neuro-hormonal factors, oxytocin and adrenaline/noradrenaline, which interact to affect the functioning of the uterus during the birthing process. The discussion section integrates this knowledge to explain and predict the physiological functioning of the uterus during 3rd and 4th stage labour both when skin-to-skin contact and breastfeeding occurs, and when they do not.

Pelvic girdle pain (PGP) affects up to 20% of the birthing population. Sufferers report pain of varying severity and frequency in and around the pelvic joints, in the hips and groin, and in the lumbar or thoracic spine. This pain is associated with activities of daily living. Pelvic girdle pain is understood to be caused mainly by mechanical dysfunction, i.e. asymmetry in any or all pelvic joints, or the lumbar spine, with muscle tightness in or around the pelvic joints possibly causing additional effects. Relaxin levels also play a role, but a much smaller one than was previously thought. This paper discusses intrapartum care for women with PGP from a midwifery perspective. Sufferers need particular specific, but easily organized, interventions to assist them in experiencing optimum health during the childbearing year. Chief among these are: community-based self-referral physiotherapy services; better-informed and aware midwives, general practitioners and other healthcare professionals; and coordination and careful communication between all healthcare providers. Perhaps the most obvious, but least frequently achieved, intervention of value would be a named midwife for each woman in order to provide caseload midwifery, and thus, follow the woman through her whole pregnancy, birth and post-birth recovery with her baby.

An intact perineum is the goal of every birthing woman. We love to have whole, healthy female genitalia. Many people consider the health of the vagina/perineum to be a matter of chance, luck or being at the mercy of the circumstances of the forces that prevail at the time of the birth.

Based on the research from my Master’s thesis, this article looks at the choices and experiences of ten BC queer couples’ births, early in the twenty-first century. It situates their births in a social context of some of the most queer-family-friendly policies in the world, as well as in a place where midwives have been able to practice legally throughout the province since 1998. I give an overview of three different types of births, from totally medical to totally natural, all the while recognizing that most families chose to experience something in between. In the end, it becomes clear that while I am talking about queer couples, there is nothing essentialist or universal about their choices or experiences. Instead, they offer insight into the everyday experiences, challenges, and choices facing most childbearing couples in British Columbia.