The third stage: the placenta and checking your body

Your baby is here, but your body is not quite finished. The third stage of labour is the birth of the placenta, followed by a careful check of how much you are bleeding and whether you need stitches. Knowing what happens means nothing in that first hour comes as a surprise.

What the third stage is

The third stage begins when your baby is born and ends when the placenta and membranes (the thin bag that held your baby and the fluid) are out. The uterus keeps contracting after the birth. As it shrinks, the patch where the placenta was attached becomes much smaller, and the placenta peels away. A few milder contractions push it down and out.

As it separates, the muscle fibres of the uterus tighten around the open blood vessels, like a hand squeezing closed. This is how your body stops the bleeding, and it is why everything in the third stage is about helping the uterus contract well. Many people are so absorbed in their baby that they barely notice being asked for one more small push.

Two ways to manage it

You can choose between two approaches in your birth preferences. Your midwife or doctor may recommend one for your situation.

Active management

Most hospitals offer this by default because it lowers the risk of heavy bleeding. It has three parts:

An injection of oxytocin, usually into your thigh, as your baby's shoulder is born or just after. Oxytocin is the hormone your body makes to drive contractions, and the injection makes the uterus contract firmly. Some places use a combination that also contains ergometrine, which is more likely to cause nausea, vomiting and a rise in blood pressure, so it is avoided if your blood pressure is high.

Waiting a short while before clamping the cord (see below).

Controlled cord traction. Once the placenta has separated, your midwife or doctor supports your uterus with one hand on your lower belly and gently pulls on the cord with the other, guiding the placenta out. The placenta usually comes within 5 to 30 minutes. Overall, active management roughly halves the risk of losing a large amount of blood.

Physiological (natural) management

No drug is given and no one pulls on the cord; your body delivers the placenta on its own. Being upright, kneeling or squatting lets gravity help. Skin-to-skin contact and letting your baby nuzzle or feed release your own oxytocin. A warm, quiet, unhurried room helps too, since adrenaline from cold or worry can slow things down.

This usually takes up to an hour. It suits people who had a straightforward labour without induction, an oxytocin drip or an epidural, and who are at low risk of bleeding. You can switch: if the placenta has not come after an hour, or you are bleeding more than expected, your team will advise active management, and you can also simply change your mind.

Side effects Nausea, sometimes vomiting None from medicine Best suited

For a minute or more after birth, blood keeps flowing from the placenta into your baby. Waiting before clamping gives your baby extra blood, which builds iron stores for the first months and eases the move to breathing air. Current guidance is to wait at least 1 to 3 minutes for most babies, including most born early, with your baby on your chest. The cord may be clamped sooner if your baby needs help breathing straight away, though some units can start that help at the bedside with the cord still attached. The cord is then clamped in two places and cut between the clamps. There are no nerves in it, so no one feels a thing. Your partner or support person can usually cut it, or you can. Put it in your birth preferences and remind the team on the day.

Cord blood: banking and donation

Blood left in the cord and placenta contains stem cells that can treat some blood cancers and disorders. In some places you can donate it free to a public bank. Private banks store it for your own family for a fee, but this is rarely recommended, because the chance a child will ever use their own cord blood is very small. Collection must be arranged before labour and should never mean clamping the cord early.

Checking and keeping the placenta

Once the placenta is out, it is examined to make sure it is complete, because a piece left inside can cause bleeding or infection later. If something looks incomplete, your team may check your uterus or arrange an ultrasound. Ask to see it if you are curious: it is about the size of a dinner plate, with a branching "tree" of blood vessels. Sometimes it is sent to a laboratory, for example after a preterm birth or a fever in labour.

Some families take the placenta home to bury it or for cultural or religious traditions. Tell your team in advance and bring a container and a way to keep it cool. There is no good evidence that eating it or taking placenta capsules helps mood, energy or milk supply, and babies have become ill from bacteria in capsules.

Normal bleeding and postpartum hemorrhage

Some bleeding is expected, and most people lose less than half a litre (about 2 cups). Your midwife or doctor will feel your belly to check the top of the uterus is firm, about level with your belly button, and watch your pads. A postpartum hemorrhage means losing more: usually 500 mL or more after a vaginal birth, or 1,000 mL or more after a caesarean. The most common cause is a uterus that is not contracting firmly enough. Others are tears, pieces of placenta left inside, or rarely a clotting problem. If you bleed heavily, the room may suddenly fill with people. That is a team acting quickly on something they practise for. In plain words, they will: Rub your uterus firmly through your belly (uterine massage) to make it contract. It is uncomfortable, and it works.

Give medicines that make the uterus contract, often an oxytocin drip plus others by injection, by mouth or in the rectum, and sometimes tranexamic acid to help your blood clot.

Empty your bladder with a thin tube (catheter), because a full bladder stops the uterus contracting.

Put in an IV line for fluids and blood tests and, if needed, a transfusion. Repair tears and remove any pieces of placenta, in the operating room if needed, where uncommon further steps such as a balloon inside the uterus can also be used.

Most people recover well, though you may feel very tired and be anemic for some weeks. Iron, food, rest and help at home matter. Feeling shaken afterwards is common too (see "When birth doesn't go as hoped"). Get help right away if, in the hours or days after birth, you soak a pad in an hour or less, pass clots bigger than a golf ball, or feel faint, short of breath or have a racing heart.

Checking for tears

Next, your midwife or doctor will look at your vagina and perineum (the area between the vagina and anus). Most people giving birth vaginally for the first time have some tear or graze. The check usually includes a quick, gentle examination with a gloved finger in the rectum, to make sure the muscle ring around the anus (the anal sphincter) is not injured. It matters, because a sphincter injury needs to be found and repaired properly. Degree What is affected How it is repaired Healing

Second-degree tears are the most common kind needing stitches. Third- and fourth-degree tears happen in roughly 3 to 6 births in 100, more often with a first baby, a large baby or a forceps birth. Afterwards you will usually be given antibiotics and stool softeners and offered follow-up and physiotherapy. Most people heal well. If you ever have trouble holding in wind or stool, tell your care provider: it is common and treatable.

Getting stitches

Stitches are done once the placenta is out, often with your baby still on your chest. Without an epidural, the area is numbed with local anesthetic, which stings for a few seconds and then takes the feeling away; an epidural can be topped up instead. Say so if you feel anything sharp, and more anesthetic can be given. The stitches dissolve on their own in about 2 to 4 weeks. Caring for them is covered in week 2 of the daily entries (day 11).

The first pee

Your team will want you to pee within about six hours, and may measure it. Swelling, stitches and an epidural can make it hard, and an overfull bladder can stop the uterus contracting. Run a tap, pour warm water over your vulva as you go, lean forward and drink to thirst. If you still cannot go, a thin catheter can drain your bladder, which brings quick relief.

Shaking and feeling cold

Many people shake or shiver hard after birth, even under blankets, sometimes with chattering teeth. It is common, harmless and usually passes within an hour, probably from the sudden shift in hormones and adrenaline. Ask for warm blankets, keep your baby skin to skin and have someone hold a warm drink for you. If you feel hot and feverish rather than shaky, tell your team.

In short

The third stage is the birth of the placenta: about 5 to 30 minutes with active management, up to an hour without.

An oxytocin injection lowers the risk of heavy bleeding; a natural third stage is reasonable for low-risk births.

Waiting at least 1 to 3 minutes to clamp the cord gives most babies extra blood and iron.

Heavy bleeding is treated quickly with uterine massage and medicines, and most people recover well.

Most tears are first or second degree and heal in a few weeks; third and fourth degree tears are repaired in the operating room and followed up. Shaking, feeling cold and finding it hard to pee at first are all common.