My midwife has asked me if I want a natural or managed third stage. What's the difference?

Medically reviewed by Hannah Dahlen, Midwife and Professor of Midwifery

The third stage of labour is when you deliver your placenta and membranes. The choice is between an active (managed) or a physiological (natural) third stage. You may be able to choose which you have.

An active third stage involves an injection in your arm or thigh as your baby is being born, as soon as his first shoulder is delivered. After the birth, the cord is usually clamped and cut within a minute.

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The injection then causes the uterus to contract strongly and the placenta to come away, so that it's delivered quickly. You don’t have to push or do anything with a managed third stage, as the midwife waits until your uterus contracts, and then pulls gently on the cord to deliver the placenta.

Most hospitals and doctors recommend an active third stage because it reduces the risk of you experiencing:

heavy bleeding, or postpartum haemorrhage
blood transfusion
anaemia

It’s also over quickly, usually in five to 10 minutes, and in most cases within 15 to 20 minutes.

A physiological third stage means waiting for the placenta to be delivered naturally. This usually takes about 20 minutes to happen, but may take up to an hour. Breastfeeding and skin-to-skin contact with your baby will help your uterus start contracting and help the third stage along.

You also need to actively help the delivery of the placenta by pushing, preferably in an upright position, perhaps squatting or kneeling and leaning forward onto a support. Cord clamping is delayed until the cord has stopped pulsating. This means that your baby gets more oxygenated blood from the placenta.

There is usually more blood loss with a physiological third stage than an active third stage, so it's not recommended if you’ve had any complications of pregnancy or labour, such as:

anaemia
heavy bleeding during pregnancy
heavy bleeding or a retained placenta after a previous birth
low-lying placenta
a twin pregnancy or other condition that might over-stretch the uterus
an induced or very long labour
an assisted birth or caesarean birth

If you have a prolonged third stage, whether active or physiological, you're at greater risk of heavy bleeding. Your midwife will keep an eye on the time and will treat you for retained placenta if a physiological third stage takes longer than an hour or if an active third stage takes longer than 30 minutes.

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If you've chosen a physiological third stage, your midwife can still give you an injection to deliver the placenta at any time. She may do this if the third stage is taking a long time, if you start to bleed more heavily or if you decide you'd rather have the injection after all.

Discuss your options for third stage with your doctor or midwife, and make your wishes clear in your birth plan.

Reviewed for BabyCenter Australia by Hannah Dahlen, midwife

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Sources

BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organisations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies.

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Danielle Townsend

Danielle Townsend is a content and communications specialist. She was an editor at BabyCenter for over a decade.

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