Placental Delivery - The 3rd Stage of Labour

Introduction

Your third stage of labour begins once your baby is born and ends when you deliver the placenta (afterbirth).  You can choose to have either a physiological (or natural) third stage or an actively managed third stage. 

A physiological 3rd stage means that you wait for the placenta to be delivered naturally.  After your baby's birth, your midwife will delay placing a clamp on the umbilical cord until it has stopped pulsating to allow oxygenated blood to pulse from the placenta to your baby. 

Your uterus (womb) will contract, and the placenta will peel away from the wall of your uterus.  The placenta will then drop down into your vagina, ready for you to push it out.  Breastfeeding and skin-to-skin contact with your baby stimulates contractions and may help your natural third stage along.  It may be easier to push your placenta out if you are in an upright position.  

Your baby's cord is usually clamped and cut after the placenta has been delivered, or when the cord has stopped pulsating. 

Your midwife will check the placenta and membranes to ensure they are complete and that no part has been left behind. 

In an actively managed 3rd stage your midwife will give you an injection of 1ml Syntometrine in your thigh once your baby's shoulder emerges.  After your baby is born cord clamping is delayed for at least one minute and up to five minutes to allow oxygenated blood to pulse from the placenta to your baby.  The cord will be clamped and then cut.  Your midwife may advise you to have an actively managed third stage if you had complications in your pregnancy or birth.

  
The injection causes your uterus to contract strongly so the placenta comes away.  Once your uterus contracts and there are signs that the placenta is ready to deliver, your midwife will pull gently on the cord while pressing on your tummy above your pelvis to support your uterus while she eases out the placenta. 

Both methods take a little over 10 minutes from the birth to when you deliver the placenta.  A physiological 3rd stage tends to take longer.

                   
The main advantage of an actively managed 3rd stage is possibly a lower risk of  heavy bleeding immediately after the birth.  You will also be less likely to become anaemic in the days afterwards.  The injection, which is used to narrow your blood vessels and stimulate contractions may occasionally have side effects such as headaches, nausea and a greater need for pain relief.

Your midwife or doctor will recommend you have an actively managed third stage if you had complications during pregnancy or labour, such as: 

• a twin pregnancy
• polyhydramnios (too much liquor or water around the baby) or other condition which over-stretches your uterus
• heavy bleeding during pregnancy or in labour
• a low-lying placenta
• anaemia
• an induced or very long labour
• an assisted birth 
• a retained placenta
• heavy bleeding after a previous birth

Whilst a physiological 3^rd stage is not recommended at caesarean section, it is possible to delay cord clamping for 1 to 5 minutes, providing that your baby does not require immediate resuscitation and you are not bleeding heavily. 

Changing from a physiological to an actively managed 3^rd stage may be required if you start to bleed more heavily. Your midwife or doctor will treat you for a retained placenta if your physiological 3^rd stage takes longer than one hour or your actively managed 3^rd stage takes longer than half an hour.

Talk to your midwife about your options for the 3rd stage of labour when you write your birth plan.  That way you can discuss your wishes and together, you and your midwife can make a decision which is right for you and your baby.

References:

Intrapartum care: care of healthy women and their babies during childbirth. 

Issued:  June 2025 NICE Clinical Guideline, Intrapartum Care NG235.

Intrapartum Care for healthy women and babies.  guidance.nice.org.uk/cg190.