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Recipes for physiological third stage

Updated: Jun 25, 2019

Maria Mills Shaw (Home Birth Lead, Epsom & St Helier University Hospitals NHS Trust)

Maria Mills Shaw sharing the joy of home birth (copyright approved)

Maria originally trained as a nurse in order to go on to train as a midwife and has never looked back.  

She has a passion for physiological birth and has honed her knowledge and skills by working in community and as a one-case homebirth caseload midwife over many years.  

Maria is currently the Home Birth Lead at Epsom & St Helier University Hospitals NHS Trust where she continues to practice with a wonderful team of dedicated home birth midwives.  

Maria very kindly offered to share her recipe for physiological third stage of labour, one that is facilitating rewards for women within her trusts home birth team.

Lies, damned lies and statistics….(attributed to Benjamin Disraeli, British Prime Minister 1874 -1880)

I love a good statistic but there aren’t that many good statistics, statistically significant statistics that would withstand robust intellectual forensic examination. So when I needed to submit some statistics to demonstrate the work and outcomes of our new Home Birth Team I took to the task like a duck to treacle.

I used a fairly standard process of counting numbers and working out percentages and overall it was a reassuring process that demonstrated that outcomes for women having home births were fabulous! No surprises there then, but when it came to our rate of post-partum haemorrhage, I was disappointed to find out that the rate was 7%. I had anticipated a rate of around 3-4% allowing time for the new team to embed practice and based on my own rate of PPH from 15 years as a single homebirth caseload midwife in the NHS of 1%.

To temper my disappointment, I decided to look at rates of PPH in the hospital (Delivery Suite) and in one of our Alongside Maternity Units (AMU) over the same time frame. What I discovered was that in the hospital, the rate of PPH (as universally defined by blood loss > 500ml or woman symptomatic) was 42% and in our AMU it was 18.4%.

I was amazed by these numbers, not so much about the Delivery Suite, as birth there is usually complicated by induction of labour and instrumental or operative procedures but I was further astounded when I looked closer at the AMU rates.

It seems that despite the AMU being a midwifery led unit focussed on physiological birth the rate of physiological third stage was staggeringly low at about 16%. This meant, over two thirds of all normal births in the birth centre received active management for the third stage! And still their rate of PPH was 2.5 times higher than at home. This possibly due to practitioner lack of trust in the birthing processes, embedding of active management for all women or maternal choice - it is difficult to say.

Statistics from our Home Birth Team show over 74% of women had a physiological third stage and our rate of PPH was lower than anywhere else in our Trust. So what do we do that facilitates this fabulous result? One that could be utilised better within AMU’s.

Slowly and Gently...Simple!

We keep the birth simple, by allowing it to progress in it’s own time, without interruption or distraction. We anticipate that the body will do the work if we respect it, give it comfort, security and sustenance. We know that oxytocin is the hormone of love, and of functional labour and we also know that oxytocin is inhibited by adrenaline and catecholamine release.

So, during birth and afterwards we ensure that the woman is comfortable and encourage her to find her space, somewhere that is warm, where light is muted or dark, we keep quiet, we keep all distractions to a bare minimum, and we sit on our hands. We don’t presume to know more about what is happening to her than she does, we nurture and support her, offering intermittent auscultation and reminding her to pass urine from time to time, mindful that a full bladder can impact on contraction of the uterus both during labour and in the third stage.

Most importantly we do not presume to tell her how to birth her baby, but encourage her to focus her own bodily sensations so that her expulsive effort is under her own steam.

When the baby is born it’s imperative to continue to keep the peace, dry the baby and put skin-skin, then wrap mum and baby up together to keep them both warm, we ask homebirthers to have a spare duvet handy for this.

When we are talking about birth with expectant mothers, we liken the effort of birth to marathon running and we tell them that just like marathon runners coming over the finishing line, they too will need to be kept warm to minimise cold muscle stress that can increase the risk of haemorrhage.

We do not use hats on babies as we believe that being able to smell the pheromones on the baby’s head will also inhibit haemorrhage. And then we wait. There is no rush! Baby can find a breast, or not, and the new mum can rest in her cosy nest having a cuppa and something to eat to replenish her. Eventually she will experience placental separation and birth her placenta with some minor expulsive effort.

So here’s the recipe

With love

Maria x

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