trish ware: [00:00:00] My name is Trish Ware and I am obsessed with all things pregnancy and birth, and helping you to navigate both the practical and the magical seasons of this journey called motherhood. I'm an all day coffee sip and Mama of seven. And labor and delivery nurse who took her expertise in the labor room and turned it into an online one stop shop.

For mamas looking for powerful education and support, I've had the amazing privilege of delivering many babies in my 15 plus year career as a labor and delivery nurse, and as a mama of seven. I'm here to help you take the guesswork out of childbirth so you can make the choices that are right for you and your baby and write the birth story of your dreams.

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Hi you guys. So today we're gonna talk about the third stage of labor. The third stage of labor is the delivery of the newborn until the delivery of placenta. So labor is done. Pushing is done, but now it's in between newborn and the placenta coming in out. So we're gonna talk about what that is, what it looks like, what might be happening, especially if you're having a hospital birth.

If you're having a home birth, it will be a little bit different. So baby has just come out. What we are hoping for and what I want you guys to ask for is for the baby to be placed right on top of you, which we call skin to skin. Skin to skin does not mean having a blanket or a towel [00:02:00] or a labor gown between you and baby.

That means legit. Everything's open and off. Baby is directly on your skin. No diaper. Nothing. Now, I always joke with my patients and with my students that I call a poit birth, and this is if your baby comes out pooping meconium everywhere. Sometimes we might slip a diaper on them, but that is really up to you in your comfort zone.

But preferably baby is on top of you without. Anything on the baby and nothing separating the two of you. What I teach my girls is we want it to be pretty hands off. Now, the labor nurses, back in the day, we used to take a baby blanket and we'd be ready for the baby to come out, and then we'd start rubbing and drying and cleaning off the verex and cleaning up the baby.

But we don't want that anymore. A light drying is okay, but not vigorous rubbing or drying. We don't want a hat on. Just want the baby on mama. Now we can put a warm blanket over the two of you, [00:03:00] or you can wrap your gown around the two of you, or like my labor gowns where you can stick the baby down inside of the gown, but you really want the baby's skin to skin.

Now what is happening to baby in between the delivery of the baby and the placenta? Typically, in a hospital birth, you're going to have a nurse or someone who is completely there for the baby, so that is not your labor nurse. This might be another labor nurse, or it might be a baby nurse. And that nurse is going to be watching your baby, and she's gonna be assessing visually the baby.

She's gonna listen to the baby's lungs, she's gonna check the baby's pulse, and she's going to be making sure that the baby is transitioning from inside to. Outside properly and she's gonna be scoring the baby. So I'm sure you've heard the term Apgar score is a scoring system that we use to assess how well is the baby adjusting to life outside of mom, and that is Apgar.

So a for [00:04:00] appearance, what color is the baby? We've got P for. For their heart rate. And then G for Grimes, is it crying? Is it, grunting, We've got the A for activity in tone. Does that mean the baby is nice and has good tone? Or is the baby floppy? And then we've got R for respiration and we're gonna be giving them a score at one minute and at five minutes, depending on the five minutes.

As long as the five minutes fine. We're not gonna do one. That we're gonna score them from zero to two points, zero being not good, two points being great. So when it comes to appearance, what color is their skin? Are they pale? Are they blue all over? They're gonna get no points if they just have blueness in the peripheral, like in the arms and legs.

They're gonna get one point if they're completely. They're getting two points. Then we're gonna check their heart rate is it over a hundred? It's less than a hundred. They're gonna get one point. If it's zero, they're gonna get zero. If it's above a [00:05:00] hundred, greater than a hundred, then they're gonna get two points For Grimes.

This means when you stimulate them, are they crying? Are they making a noise, are they reacting? And so if they're really crying and screaming when I rub them, then they're gonna get a two down to no response, Would be a zero for their activity. Are they floppy? That's a zero. If they have some what we call flexing or flexion then this is going to be one point.

And if they're really, tight and tone is good, they're gonna get two for respirations. If there's no respirations, obviously a zero all the way to strong respirations, they're gonna get a two. Most babies are gonna get like an eight for a one minute and a nine for five minutes. And this again, depends on whether the labor nurse is scoring them.

Or a baby nurse. Baby nurses are a little stingy with their numbers. Labor nurses are way more giving and we'll throw out a nine and a 10. No. . So the baby's gonna be assessed while the baby's laying there. Again, we're gonna listen the heart rate and the respirations, and that can [00:06:00] all be done on top of you.

Now, depending on how well they are adjusting, and depending on the Apgar score will tell me what do I need to do next? So if the baby has a low Apgar score, then they're gonna need some sort of resuscitation and possibly they're gonna be taken to the warmer for resuscitation. Now there is a lean that's going toward.

Resuscitating on top of mom, which makes so much sense because your baby actually naturally resuscitates it on itself on top of you. It not only is regulates their temperature, which is important on top of mom, it also regulates their blood sugar, which is also important. and it also regulates their breathing.

So all these important factors of transitioning to life outside of MAMA can happen on top of mom. So there is this new lean and trend towards resuscitation on top of mom, but not all places have gotten there yet. So I always tell my students inside of my birth classes that. Resuscitation, tops, everything.

So if your baby is [00:07:00] not breathing or your baby needs resuscitation, then yes, that's more important than skin to skin. However, immediate skin to skin can reverse a lot of things that might be going on. So again, baby's out, Baby's on top of you. Now, what is baby doing? Typically, they're gonna be acclimating to this world, right?

They're gonna be using their senses to figure you out. They're smelling you, they're hearing you, they're feeling you. They're seeing you. So you wanna have them, on your chest. Nice and close. I always say, Day dirty. You've got that amniotic fluid and that verex all over you. That helps them acclimate as well because it's familiar.

Your voice is familiar, your heartbeat is familiar, so it's just amazing. We're gonna do a whole nother video and podcast on that as well. So babies on top of you, do you have to force them onto your breast or any of that? No. Be laid back. All of those things you're doing right now is leaning towards a good breastfeeding start, and we'll talk about that in another episode as well.

So now, what is your provider? What are the [00:08:00] providers doing? What's your labor nurse doing? So your labor nurse is usually right there at bedside. She's watching you, she's watching baby, and she's watching the doctor for some signs and clues. So we're gonna talk about a couple different ways that providers might manage the third stage of labor.

So there's something called active. Active management means they have their hands on. They're gonna give you a uto medication after delivery, which is typically Pitocin. We're gonna talk about that in a minute. They're gonna clamp that cord, cut that cord, and they're gonna control the umbilical cord, what we call traction or controlled pulling of the umbilical cord until the place.

Separates from the uterine wall and is delivered cuz that's what we're waiting for. We're waiting for the placenta to separate from your uterus, from the uterine wall and then come out. So if they're planning on doing an active hands on method, then they're gonna give you, like I said, a utero medication.

Typically Pitocin is the one that we use which is synthetic [00:09:00] oxytocin. And that is usually the one we do. So a uterine medication will cause contractions of your uterus. Some midwives and some providers that I work with will also use Cy attack and they put it in your booty. And that's how that works.

Nothing by mouth is going to work for postpartum hemorrhages or for management or what we would call like prophylactic treatment. Of potential postpartum hemorrhage something by mouth wouldn't work cuz think about it, it has to go through your digestive system and then you're not gonna get as much.

Plus it takes a while. So you're either gonna get an injection of Pitocin or if you have an IV running, you're gonna get Pitocin bo list into your iv. Typically, we're gonna give you a 500 mil ml bag that has 20 units in it already, and we're just gonna put it in Now for most women in the. We do a hybrid type of active management.

I'm gonna get there in a second. Another type of management, which is what I recommend for my students if they don't have [00:10:00] any postpartum hemorrhage. Risk factors is expected management, expectant management, and that is hands off. Completely keeping their hands off. That means they're not gonna give you medication.

They're not gonna cut and clamp. They're not gonna clamp and cut the cord, and they are not going to, tug or pull or control, pull the cord to get the placenta to come out. They're gonna wait for that separation of the placenta from the uterine wall without any. Interventions without getting in there and doing any of that.

And usually with expected management. And I just did a workshop with another birth professional and we were talking about this for her home birth with her second. The placenta wasn't coming out as quick, and so the midwife just had her stand up, pushed a little. Came out. So with an expected management or a hands off, the placenta might be delivered by gravity or just spontaneously, [00:11:00] mom exposes it.

What we see more often in the US now, I've been a labor and delivery nurse for many years, for over 15 years. And then a birth educator since 2017. Is a mixed, like hybrid between active, between expectant and that is usually using some Pitocin with the hands off approach. So they're still giving you the medication, but they're not doing, they're not cutting clamping and cutting the cord and they're not doing any kind of controlled pulling of the cord really.

All of this goes based on your risk of postpartum hemorrhage. So let's talk about what would be risk factors for a postpartum hemorrhage. Let's say you had a very long labor, or you had a lot of pitocin, like you, what we call a serial induction, like days of being induced in lots of Pitocin. You had more than one.

You had multiples or you've had a lot of babies like this girl, cuz I've delivered six, so I'm very [00:12:00] high risk for a postpartum hemorrhage. Or you had preterm light labor medications or you had magnesium for preeclampsia or something that would make your uterus not as apt to contract and constrict and go back to normal because that's what we're wanting.

We're wanting that uter to get nice and hard and firm and go back to its normal size. Postpartum hemorrhage is frightening and it is one of the leading causes of maternal death. I think 4% of women have a postpartum hemorrhage. So we need to be actively assessing and we need to be assessing your risk before delivery.

You need to be educated on what we do and why we do. Is it right for you? Because you have a right to make a decision. You have a right to refuse postpartum Pitocin. You have a right to do all these things, but should you, I tell my students we don't want anything out of convenience or curiosity, but we also don't wanna go into labor and delivery with hard nos and hard yeses because there is a reason for [00:13:00] everything.

The most common cause of a postpartum hemorrhage is called uterine acne. Uterine acne is when your. Is sane, soft, and what we would call boggy. And it's not constricting and it's not constricting down back to its normal size. So it's not expelling all the blood and the tissue and getting back to its normal size.

And that is the most common cause of postpartum hemorrhage. So one of the things that your nurse is going to be doing in that immediate postpartum after your placenta comes out, Whether we've given you Pitocin or not, we're gonna be assessing you every 15 minutes. We're gonna have your blood pressure cuff ongoing, checking your pulse.

We're gonna be looking at you. Is she okay? What is she saying? Is she saying that she doesn't feel well? Is she lightheaded? Are we seeing any trends with her blood pressure and her pulse? And we're also gonna be doing the dreaded. Fun massage. Now, what I wanna tell you about the fun massage is that it doesn't have to be hell.

It doesn't have to be [00:14:00] horrible. Now, there are some nurses that do it very aggressively. It's not absolutely necessary. But one thing that I do when I do the first one, which is usually your provider will do it right after she's done stitching you up and getting you cleaned up. And I'll talk about that in a second cuz that also happens.

Right after the placenta is when she's gonna do any repairs, which we'll do another podcast about that. I keep saying that, but that's a whole nother podcast. So once the provider's done placenta's out all as well, you're cleaned up, we've put some pads, we've put an ice pack on, we've gotten you up in the bed.

Your nurse is gonna move in, and now it's her territory. Everybody else is gone. Your nurse is gonna turn. Down baby's eyes are gonna pop open during this active stage or alert stage, and she's gonna start doing your fun massages every 15 minutes for the first hour, and then every half hour for the second hour.

And what that means is, I'm gonna go to the top of the fundus, which is right here, the top of the uterus, but now it's down here at [00:15:00] your belly button and she's gonna be finding it. So I'm gonna be palpating your tummy and feeling like, where is the fundus? Once I find it, I'm gonna take my fist and kind of miss.

Massage it to see. What I'm feeling for is the tone of your uterus. Remember I said uterine acne is the leading cause of postpartum hemorrhage. So I wanna feel that it's nice and hard and firm. I don't want it to be mushy or boggy. And I'm gonna also be looking at your vagina to see like what's coming out, like how much blood is coming out when I massage it.

If a lot is coming out, then I might massage it longer and I'm gonna decide am I comfortable with the amount that's coming out? And if I'm not, I'm gonna get your provider back in. Then we might take some next steps. If you haven't had Pitocin, we might give you Pitocin. If we've given you Pitocin, but I'm still not comfortable with it, your provider's gonna assess and we might take some higher level steps.

If it's trickling out and it's not stopping, then I'm gonna massage a little longer until I get that trickle to stop. [00:16:00] Again, if it doesn't, I'm gonna call your provider back in the room. And so we're gonna be doing that every 15 minutes because we want to see the bleeding going down. We wanna see your uterus nice and firm, and we wanna see it.

Staying right there in the middle. So right here at the belly button. I don't want it over. If it's deviated over, it might be telling me something isn't right. If it's staying boggy, then another cause of uterine postpartum hemorrhage could be tissue inside of your uterus, which maybe there's placenta or membrane left inside.

So in that case, the provider might have to come in and get it manually, get that out of your. Not fun if that happened to you. Sorry. But we need everything cleared out so that the uterus can contract down and you can get nice and healthy and move on to the postpartum room. So another cause of postpartum hemorrhage could be trauma, like tearing to the uterus or the cervix or the vagina, the perineum or the episiotomy.

And then cause would is what we call thrombin. This is the least common [00:17:00] cause of postpartum hemorrhage. Maybe less than 1% of women. You may have a genetic or a known or unknown clotting disorder. You may have low placentas or some other reason that is causing you not to stop bleeding. Postpartum hemorrhage typically is when you have.

500 mls of blood within the first 24 hours. Now you're gonna see a lot of blood and you may think, Holy crap, I've lost a lot of blood. This is way more than I should and I need help. But we're pretty used to it and we can assess that. It looks like a lot of blood. Typically it's not, and some women handle more blood loss.

Some women might have less than 500 loss and they are having signs and symptoms. If we feel that you've had a postpartum hemorrhage, we're gonna assess on whether or not you need a blood transfusion. If you need a blood transfusion, then we're gonna do that in labor and delivery before we ever send you over to post.

Typically a severe postpartum hemorrhage would be considered greater [00:18:00] than a thousand mls lost in that first 24 hours. And typically when we have this blood loss, most often than not, these postpartum hemorrhages are gonna happen when you're still in labor delivery. But many happen over in the postpartum unit, and that's why assessment.

So important, speaking up, telling your nurse if you don't feel right, if you feel dizzy, if you're seeing more blood than you're comfortable with, speak up and tell your nurse. So I hope this helps you guys just a little bit with the third stage of labor. I think we all talk about the first stage, which is early and active labor, and we all talk about the second stage, which is pushing.

And the fourth. Postpartum, but a lot of people don't talk about the third stage of labor. So I hope this helped you guys a lot. If you have any questions, make sure you shoot them over to me. If you're seeing the video on YouTube, put it in the comments. If you're listening to the podcast, be sure to hit, subscribe and post a review.

I hope you enjoyed this episode of the [00:19:00] Birth Experience with Labor Nurse Mama. Where I broke down the third stage of labor. If you loved this episode and you wanna hear more like it hit, subscribe, write a review, and as always, I'll see you again next Friday. Bye For now.