“I am really supportive of women being able to have a physiological third stage,” she said, “but I haven’t had many chances to facilitate this and some of you seem to have a lot of experience of it. Would you each share with me a tip or piece of advice?”
The question was asked by a midwife who attended a workshop that I was co-facilitating in Hamilton, New Zealand. I was sitting with a group of midwives and birth workers from around the world (the UK, New Zealand, the USA, Australia and South America), facilitating a discussion about the birth of the placenta. I had invited each woman in turn to raise a question or topic for discussion and, as we sat in the sun, we mused on topics from oxytocics to lotus birth. When it came to the turn of one midwife, she asked the question above.
‘What a great question’, I thought!
Exploring midwifery knowledge…
As we each shared our thoughts within the circle, I was again reminded of the value of midwifery knowledge. Of what can be gained by sharing what we know, by talking about the everyday things that we do without even really thinking about them. And, in this example, also by talking about what we don’t do. Even as the women talked, I began to think about whether we could try and capture some of the discussion that had emerged on paper. Not because this is a more valuable form of communication of such knowledge, for I am not at all sure that this is in fact the case. Nor because facilitating placental birth is a topic that has never been discussed elsewhere. But because I know there are others who would have loved to ask the same question as our friend. And such important topics deserve to be discussed regularly.
As we moved from sharing our thoughts to making tea, I asked the group if they would be open to writing their tips and thoughts down. This article is the result. Each of the tips was given by a different person, so there is inevitably a bit of overlap. But I have left such overlap in because it helps to highlight what the core issues are.
1. Leave them be…
Once the baby is born and secured in mum’s arms, leave them be.
Do your assessments unobtrusively and gently and wait for a placental ‘gush’. Maintain a warm, safe, dim, quiet environment.
Just be patient. As long as mum and babe are well, just be patient.
Make cups of teas, toast, encourage breastfeeding, write up your notes.
The woman will let you know when she is ready, either by saying she is feeling pressure building down low, or just by birthing her placenta!
3. Be quietly expectant…
Babe in arms, skin-to-skin, ignore the placenta by not mentioning that phase and be unobtrusive and quietly expectant; observe for signs of separation and mother’s own urgings.
Support a woman by informing her earlier on in her pregnancy about placental birth — facilitate her to do her own research as she is making the choice. Having her write down her wishes on paper which you can put in her notes may be helpful for the people supporting her.
5. Don’t touch, don’t talk…
After the birth, don’t touch the cord; ensure that mum has time to meet her baby. Keep the mother warm with blankets and make refreshments: ideally warming drinks. Let the mum and dad lead their own discussion. I’ve learnt not to talk, as I feel the flow of oxytocin is disrupted if the midwife/birth attendant dominates the conversation. Most of the time placentas have birthed within an hour and a half of the baby’s birth time if the above has been allowed to happen. Physiological birth of the baby should be followed by physiological birth of the placenta. Syntocinon is an emergency drug and doesn’t belong in normal physiological birth.
6. Hold space for love…
The work of the midwife after the baby is born is just to hold the space for love to happen. Don’t let anybody interfere with this sacred and important moment in which love and interaction should happen. The interference can be from talking directly to the mother, other professionals, the mother not feeling comfortable, someone talking on the phone, someone trying to ‘help’ with breastfeeding and forcing the baby’s mouth on the breast, and all of these can distract the mother from her baby instead of just being in the moment. So hold the space, protect the space of mother and baby so they can meet each other in their own time and rhythm.
7. Let nature do her work…
The baby’s weight on the mother’s belly will help to contract the uterus; the interaction helps release oxytocin to contract the uterus, breastfeeding releases oxytocin that contracts the uterus; so protect nature, for she takes care of it! Just be there in case you are needed, but if you let nature do her work, you should not be needed.
Read books by Sarah Buckley and Michel Odent to understand the cocktails of hormones that are paramount for the birth of the baby, placenta and love making. And, more recently, we can add this oxytocin research and the updated Birthing Your Placenta.
9. Mindfully watch
After the physiological birth of the baby, mindfully and quietly watch the uninterrupted mother and baby interact; leave the umbilical cord intact. While the mother and baby stare into each other’s eyes, baby close to the breast, licking and tasting (don’t forget to keep mum warm and nourished) they will fall in love. This will start to spike mum’s own natural oxytocin in pulses, creating both more love and contractions of the woman’s uterus to help separate the placenta, which will lead to the placental birth. There is no need to separate the baby from the placenta until the placenta is out!
Trust that the woman’s body knows how to finish the birth. Women’s bodies know when to birth and how to birth. Following the birth of the baby it is nonsensical that the woman’s body will not know how to birth the placenta. The keys are: skin-to-skin, uninterrupted time for mum and baby, baby-initiated breastfeeding … all of these promote physiological birth of the placenta.
Vigilance and mindful watching
Sometimes, articles on topics like this can be taken the wrong way, in that some people will read the take-home message as being that nature will always work and the midwife doesn’t ever need to do anything. I don’t think this is what the women who are quoted above are saying at all. If you read their words carefully, you will see that their urges to trust nature and promote love are interwoven with reference to the concurrent need to observe, to assess, to mindfully watch. In some cases, their vigilance may be unspoken, but it is there. They may be sitting quietly in the corner, but they are watching and waiting.
Perhaps, to use a term that Tricia Anderson coined to describe the way in which midwives can be extremely observant and mindful while appearing to be doing nothing at all, and as Liz Nightingale mentioned (2013:18) they are ‘drinking tea intelligently’. They look as if they are merely marvelling at how easy their job is, while they are unobtrusively estimating blood loss, assessing a woman’s condition, watching for signs of placental separation and noting how long has passed since the birth of the baby.
The search for balance
The words of the midwives also give a bit more insight into the balance that needs to be struck between letting things be and moving things along, where the notion of moving things along — unless there is a true emergency — is rooted in the concept of first doing no harm:
‘If you do feel you need to move things along, do this unobtrusively. But before you do anything, ask yourself: is this for the well-being of the mum, or the baby, or the midwife, or someone else? Yes, if the mother is bleeding or showing signs that all is not well, of course you need to act, and sometimes fast. But mostly, all will be well’.
‘There are things you can do to facilitate the birth of the placenta if you really need to that maintain the energy that promotes the oxytocin you need. Change position, sometimes it works to go back to the birth position, or squat, sit on a toilet. While the woman is there, she can try passing urine. If things are slow and the woman is ready to move on but you’re not worried, try a shower. It’s always worth considering removing other people from the room to secure privacy. Talk through the barriers; explore emotional stuff…’
Acknowledging the complexity
Many of the articles that you will read about placental birth — a term that I use deliberately in order to circumvent the convention of dividing the journey of labour into artificial stages and to emphasise the woman birthing the placenta rather than being delivered of it — will focus on the frequency and severity of postpartum haemorrhage, often using this to justify the routine use of drugs and intervention during the birth of the placenta. Nothing in here should be taken to reduce the value of knowing how to deal with haemorrhage when it occurs. Yet it is clear — perhaps never more so — that this area is complex.
The past few years have seen a weakening of the supposed correlation between managed placental birth and reduced postpartum haemorrhage (Edwards 2010, Fahy et al 2010, Begley et al 2011, Edwards & Wickham 2018), an increase in the evidence showing that the use of artificial oxytocin and birth interventions increase a woman’s chance of bleeding as well as causing other undesirable outcomes (Buchanan et al 2012, Endler et al 2012) and the raising of even more questions about the safety of synthetic oxytocin (Simpson & Knox 2009, Kurth & Davalos 2012). When we put this data alongside the growing calls for us to respect the cocktail of hormones that nature has provided for birth and disturb it as little as possible (Buckley 2011), we might conclude that we need to drink more tea more intelligently and continue to share our experiences of physiological birth.
I would like to thank the participants in Birthspirit’s Mind, Body and Spirit workshop 2011 for sharing their wisdom and for being a part of the circle from which this article emerged.
Begley CM, Gyte GML, Devane D et al (2011). Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews, Issue 11.
Buchanan SL, Patterson JA, Roberts CL et al (2012). Trends and morbidity associated with oxytocin use in labour in nulliparas at term. ANZJOG 52(2):173-8.
Buckley S (2011). Undisturbed birth. AIMS Journal 23(4):4-7.
Edwards N (2010). ReView: What information do midwives and women need to be able to make decisions about the third stage of labour? EM 1(6):27-30.
Edwards N, Wickham S (2018). Birthing your placenta: the third stage of labour. Avebury: Birthmoon Creations.
Endler M, Grunewald C, Saltvedt S (2012). Epidemiology of retained placenta: oxytocin as an independent risk factor. Obstetrics and Gynecology 119(4):801-9.
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 haemorrhage: a cohort study. Women and Birth 23(4):146-52.
Kurth L, Davalos D (2012). Prenatal exposure to synthetic oxytocin: risk to neurodevelopment? Journal of Prenatal and Perinatal Psychology and Health 27(1):3-24.
Nightingale L (2013). Birth noises and normal birth: midwifery by ear. EM 4(4):17-23.
Simpson KR, Knox GE (2009). Oxytocin as a high-alert medication: implications for perinatal patient safety. MCN – American Journal of Maternal Child Nursing 34(1):8-15.
photo credit: Keoni Cabral via photopin cc
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