Episode 129 - Giving birth to the placenta
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey.
[0:21] Hello, Rebels. In today's episode, we're talking about placental birth. I'm first going to start by describing what the placenta is, how to give birth to your placenta, and three strategies or options for placental birth, including psychophysiological, physiological, and active management. And for clinicians out there, I'm also going to give some really practical steps on how to facilitate physiological birth. And if you're listening as a birthing woman, then you'll understand the different options for your birth and have all the information that you need to choose how you want to give birth to your placenta.
[1:00] All right, so what is the placenta? So the placenta is actually the genetic material of your baby. So when they have a look at it on a histological level, so the actual tissues, the baby grows its own placenta and so it's not the maternal organ, it's the fetal organ or baby organ. And for that reason, some people do really hold it as a sacred organ. Lots of cultures have a lot of ceremony around the placenta, around the burial, around the cutting of the placenta off from the baby. So there's all kinds of practices that honours the placenta as the baby's possession. But certainly the baby grows it. The baby uses the placenta to implant itself to the inner layer of its mother's uterus. The uterus has three layers and on the very internal layer is where the placenta will implant. Most of the time, it implants in a healthy way and there are abnormal placentation processes, but that's not the topic of today. We're going to talk about normally implanted placentas today. So the size of the placenta roughly approximates to about one-sixth of the weight of your baby.
[2:19] So that's roughly how big your placenta is going to be. And it should, in a healthy pregnancy, stay attached to the side of your uterus for your entire pregnancy, your entire birth. The baby is then born and then your body goes through a process of giving birth to the placenta. Once your baby is born, that's not birth finished. and obviously I'm a home birth midwife so I speak a lot to my clients about the labour process and birth process and you've not finished until you've had your placenta and you're no longer bleeding excessively as a result of having given birth to your placenta. So there's still effort involved in giving birth to your placenta if you are in charge of that process. If the placenta the birthing process is handed over to the clinicians at your care. So if you have a midwife or an obstetrician at your birth, a lot of those healthcare providers will assume responsibility for your placental birth and you might not even realize it's happened because usually the placental birth process or what mainstream maternity would call the third stage of labor, placental birth, is completely managed by your healthcare provider. And we're going to talk about how they manage that and why they manage that.
[3:39] But if you were to leave it alone to give birth by itself, once your baby is born and your uterus is empty of baby, it kind of collapses in on itself, contracts like it would if you were having a contraction to bring your baby out. And because the placenta is not flexible and can shrink like the uterus, It sort of gets sheared off the side of your uterus, but also in that process builds up this blood clot behind the placenta, which kind of acts to push it away from the uterus wall.
[4:17] And actually, if you're interested in seeing what this looks like on the placenta, I actually have a full placenta tour. On my Instagram page at MelanieTheMidwife. And it's a completely undisturbed placenta. The woman gave birth to it and you can see the whole placental clot that comes behind the placenta on it.
[4:38] It's a full tour of what it looks like. So some blood loss with the birth of the placenta is actually part of the physiological process of pushing it off the uterus. So we expect some blood loss but not too much. But that's the very basics of how it comes off the side of your uterus. And then there does need to be some element of gravity or downward pressure for the placenta to be born. It doesn't really get pushed out like the baby does. It usually relies on a little bit of maternal effort or an upright position in order for it to come out. Some women give birth to their placentas in the water where there's less gravity. But in my experience, women more likely need to either hop up onto their knees, sit on the toilet or come up out of the pool in order for the placenta to release out of their uterus and through the cervix and out of their vagina.
[5:33] And the placenta will hopefully not detach until the baby's finished with it. There is a transition process that when your baby's born, it transitions from receiving all its nourishment and oxygen. And then almost immediately, within a minute or two, completely transitions to breathing air. And it's not until that moment that the baby's body will internally cut off supply to the placenta. But if that process hasn't properly happened and the baby hasn't fully transitioned, hasn't been able to take a good effective first breath, then it will still keep pumping blood through the cord and any blood that's in the placenta is actually part of the baby's circulation. It's not the mother's blood in the placenta, it's the baby's. The baby's blood and maternal blood never actually mix. So maternal blood can transfer nutrients, sometimes medications, oxygen, and everything through into the baby's blood supply. But it kind of floats out of the woman's blood supply and absorbs into the baby's blood supply without the two having to mix and interact. So the woman can have a completely different blood group to the baby and that's okay because there's no actual blood mixing.
[6:52] So any blood that comes out of the placenta has all been in and belonged to the baby its whole life. It's never been maternal blood. So when the placenta detaches, usually it's because the baby's finished as well. So there's an interaction between the mother and the baby. So if the cord's still pulsing and the placenta's still attached, it's possible that the baby still needs it after being born. So we don't rush the process of placental birth for that reason because there's a physiological process going on to not only keep the woman safe, but the baby safe as well. And the hormonal process that goes along with the placenta removing itself from the uterus is that once your baby's born, you'll actually get the highest oxytocin hit that you'll ever have in likely your whole life and higher than it was during the birth.
[7:42] And oxytocin not only encourages bonding and love. So the minute you see your baby, there's just an immediate hormonal setup to fall in love with it. But oxytocin also is the hormone that contracts your uterus, which facilitates the separation of the placenta and also keeps your uterus contracted to reduce postpartum blood loss. And so if that physiological process is all intact, the placenta should come away by itself and the woman shouldn't bleed excessively after the birth. The baby should have time to receive any oxygen and nutrients it needs from its placenta before it cuts off that supply and fully transitions to breathing air. That's the physiological process of the placenta coming out. Also, we don't cut the cord in that process. The baby stays attached, in which case it also must stay with its mother and part of the physiological process of placental birth is that the baby and the woman are not separated. If we think about how this third stage of placental birth is kind of, I'm saying managed by inverted commas, how it's managed.
[8:53] We could break it up into three different options, I suppose, for how your placenta is going to come out. For a long time, midwives have spoken about physiological placental birth or actively managed placental birth. But there's a third option, and that comes before the physiological. It's the least, least, least medical option for placental birth. And there's some research by Hastie et al. Again, it'll be all in the resources. is if you're on the mailing list, you have access to the resource folders. This will be in there. In 2009, wrote about psychophysiological placental birth. This was a differentiation between straight what we've come to think of as physiological birth. So I'll take you through the three. We'll start with psychophysiological birth. We'll talk about physiological birth and we'll talk about actively managed placental birth because these are the kind of three ways your placenta is going to come out. Later on, I also want to talk about placental birth after having had a cesarean. So psychophysiological placental birth focuses on the actions of a midwife who's known to the woman or chosen by the woman to attend their birth in an also physiological setting like a home birth or in some birth centers that are very low intervention.
[10:17] So this is a type of placental birth that can't be mimicked at all in a hospital setting, no matter the skill of the midwife or the philosophy of the midwife or how physiological the midwife believes they are or how straightforward the birth is, if you're in a hospital and you're in.
[10:36] Can't have had a psychophysiological placental birth because it relies on the interaction of the birth environment. Very, very limited intervention. And one of the biggest interventions that there is in birth is getting in the car mid-labor, driving to a new strains facility and entering that facility. Already by moving yourself into hospital, you've taken yourself out of the psychophysiological option of placental birth. You can still have a physiological placental birth, but it's not the holistic placental birth care that we're talking about in this section and what these researchers are talking about. So it relies on the midwife being known to the woman.
[11:21] Enhanced feelings of safety, a familiar environment where the woman feels comfortable and safe, low intervention birth where the woman is at low risk of postpartum bleeding, and the care of a midwife who's provided holistic care, which includes the physical, psychosocial, social, emotional, cultural safety that's offered in that kind of birth model. So it's already a pretty boutique option for placental birth. And there's research on the effectiveness of this type of approach to placental birth. And if you read the paper, they detail in full lists of what factors would make it a psychophysiological birth process. So they talk about this thing of midwifery guardianship of the placental birth process. So a psychophysiological approach to placental birth relies on the meeting of certain, I guess, eligibility criterias. So firstly, it has to be a model of care where the woman has had that midwife be her primary care provider. The woman's had a healthy pregnancy and we're not expecting any unique complexities, which.
[12:38] The woman has information about and has discussed birthing of placenta. So basically, we've sat down and had a complete education session about placental birth, how it works, what it involves, so that when the woman comes to giving birth to her placenta, she's aware that it requires her effort and her attention. And so the woman has to be well prepared. So this can be a difference between
[13:03] psychophysiological placental birth and just straightforward physiological birth. That the woman has been actually prepared and educated about placental birth and that she's consenting to this way of doing it. And she's agreed that this feels like the best way for her to birth her placenta. And they talk about the woman being in a mindful, having a mindful approach towards placental birth. So not just kind of having the baby and then forgetting about the rest of the process.
[13:34] It's only best to do physiological or psychophysiological placental birth if the rest of the labor of the birth has been uncomplicated. So was it a normal vaginal birth without too much interruption? If it was, you can kind of move on into the process of also having an uninterrupted placental birth. The next criteria for this psychosocial placental birth is that the woman and her baby are physically and emotionally healthy at the end of the second stage. There are some times at a home birth, for example, where the woman's had her baby and just looks at you and says, I do not want to give birth to my placenta. Can you just sort that out? I don't want to put the effort in. You know, it might have been a long labor. She might be emotionally exhausted. It might have, you know, her expectations of it might have been different and she's just not up for birthing the placenta now.
[14:27] And that's okay, that the attending midwife knows how to act as a midwifery guardian to preserve the physiological state that's required for psychophysiological birth. And that means that the midwife's not touching anything, not saying anything, is protecting the birth space from intrusion, keeps the lights down, the room's still warm, isn't poking around on the woman's fundus and uterus, isn't kind of injecting any activity into the birth space. So there's a way of being with a woman that will actually allow her to be in an optimal state to give birth to the center. Also, immediate and sustained mother and baby skin-to-skin contact so that you don't separate the woman and the baby. The mother and baby are kept warm, so all fans turned off, everyone's wrapped up in a nice big blanket.
[15:20] The baby's allowed to self-attach to the breast. The woman's in an upright position, which I was speaking about earlier with just the assistance of gravity to bring out the placenta. The midwife unobtrusively observes for signs of separation of the placenta and the placenta is born entirely by maternal effort and gravity with no cord tractions and no pulling on the cord, no fundal massage. And the midwife is just there to gently encourage and be present and mindful with the woman and give gentle reminders for the woman to focus on her baby and the birth of the placenta ahead of anything else. And then it also relies on the partner or support people to ensure that their interactions in the space remain focused on the woman and baby dyad until this placental birth process is complete.
[16:16] We have to call it the halo, don't we? like having that halo around the family to protect it. Absolutely. And, you know, I talk to women as well about sometimes if their children haven't been in the birth space during the birth and then the baby comes out and they go, oh, go wake up the kids, it's time to tell everybody and call mom. And like, whoa, hang on, we're not finished yet. Like if you suddenly go and inject three excited children into the space and get on the phone or I've seen women like in Zoom conference calls with, you know, somebody overseas to show off their new baby and the placenta's still inside. We've got to protect this space. So there's a whole lot more to the psychophysiological placental birth process. And I really encourage you to read that article, which is called, so it's by Caroline Hastie, 2009, Optimizing Psychophysiology in the Third Stage of Labor. There's a whole lot of steps there on how we can be.
[17:15] A midwife to facilitate this kind of placental birth, but know also that it's
[17:20] not possible in a hospital to do it this way. For the midwives who are feeling triggered of like, how dare you say I can't provide a psychophysiological birth experience for women in hospitals? We've got to remember actually, it's not about us. There's a whole system out there that's failing birthing women at every single point and you're not responsible for that failure you know a lot of midwives are in the system every day battling against a medicalized system being a physiological midwife you can provide care for women wanting a physiological placental birth there's no doubt about it your head's in the space you've managed to fight off all the powers that be to keep a birth space safe for a woman in a hospital to have a physiological placental birth, but you in a system are powerless to provide psychophysiological birth care because that relies on a woman not being in a hospital. Yes, you can keep providing physiological care in a hospital, but what we're talking about in this first option is psychophysiological care and that's a completely different ballgame.
[18:33] Okay, so the main reason we intervene in placental births is that we are terrified of postpartum hemorrhage. So then they did research on this way of caring for women, psychophysiological placental birth. So when they had a look and compared psychophysiological placental birth care to just regular placental management, what we call active management, which I'm going to talk about in a minute, in hospitals. So if you're a woman and you're low risk and you have low risk of bleeding after your birth and you go to hospital and accept or receive active management of your placenta, and that's just standard care in a hospital.
[19:18] Then you've got an 11.2% chance of still having a postpartum hemorrhage. When they had a look at the same type of woman, low risk, low risk of bleeding, who is exposed to holistic psychophysiological third-stage care, the postpartum weight was 1.7. So it's seven to eight times less likely to have a postpartum hemorrhage if you honour a holistic psychophysiological third stage versus an actively managed third stage in hospital for a woman of equal risk. So this is not low-risk women compared to high-risk women. So it absolutely works to use this psychophysiological third stage management if we have an intention of reducing postpartum hemorrhage rates. That's where the research is because that's the only reason why we interrupt placental birth is that we want to reduce the amount of time where a woman is at risk of bleeding. And the belief is that if we get the placenta out fast, we're going to reduce the woman's chance of having a postpartum hemorrhage. But what we're seeing now in research over the last 20 years, really, is that the assumption that interfering with the third stage will reduce postpartum hemorrhage rates is kind of not true.
[20:41] We've ignored the psychophysiological process of birth. And that's a medical assumption is that we can do better than what the body can do. And so if you leave us to it, if you just let us manage this, you could be kept safe. And it's forgotten that actually for most of humanity's existence, we haven't had oxytocin injections to bring out placentas. So, of course, there would have been women who bled postnatally as a result of, you know, and died from PPHs. But it's not 100% of women who would have a bleed without medical attention. And so then I guess if we move on to the next kind of option of physiological placental birth. This could happen in a hospital. You could have not an actively managed placental birth in a hospital. I do believe that's possible. And there is stats on this. You know, we aren't really taught either at uni or at hospital how to support a physiological third stage because hospital policies are that we actively manage placental birth. So I've just pulled up a paper here and And the title is Outcomes of Physiological and Active Third Stage Care Amongst Women in New Zealand. So New Zealand midwives, way better than Australian midwives at physiological third stage.
[22:03] New Zealand has a history of, well, a better history than Australia of supporting physiological birth. I'm sure if you're in New Zealand, you might think, well, it's not that great. I can promise you it's better than Australia. Yeah. So basically, they've got an opportunity to study physiological versus active management. And I realize we haven't yet explained active management, we will. But if we're thinking about the reason that medical people think that the third stage should be managed is because they fear that there's a high risk of PPH and that actively managing the placenta, the placental birth is going to reduce that chance. So.
[22:42] This is research done in 2013 and they compared the rates of bleeding for if you had physiological third stage care, which in the research they sometimes call expectant management. So in researchy words, expectant management is kind of the words for like not doing anything. So what would happen if we just didn't do anything? And then they compare that to an intervention. So in this case, the expectant management was let's just wait for the placenta and the active management or the intervention was to give oxytocin and bring the placenta out without the input of the woman. It was all clinician-led.
[23:20] So in this study, 48.1% of the women in the study had a physiological third stage birth of the placenta and 51.9% had active management.
[23:32] So the findings were, and I'm reading this word for word, women who had active management had a higher risk of blood loss of more than 500 mils. The risk was 2.7 when a woman was actively managed when compared to physiological management. So they're saying there was a two point increase risk 2.7 fold if you had active management versus physiological management. So things like manual removal of the placenta where you actually have to go in there and manually remove the placenta from the uterus was more likely in active management. So 0.7% of women who had active management required manual removal versus 0.2% in the physiological group. And so they concluded in this study for women who were given oxytocin or a uterotonic drug as treatment rather than prevention for a postpartum hemorrhage of more than 500 mls was twice as likely in the actively managed group compared to the physiologically managed group. So what they're saying is if you had oxytocin injection to prevent postpartum hemorrhage, you were twice as likely to need further medication to stop to treat an actual hemorrhage. You were twice as likely to require treatment to treat an actual hemorrhage if you were given preventative medication to prevent a hemorrhage. So –.
[25:01] What this research is saying is actually, is prophylactic, so preventative oxytocin and actively managed placental birth actually fulfilling the need that we think it's fulfilling of preventing PPHs? From this research, no, it's not by any means.
[25:20] And they've concluded that the use of physiological care during third stage should be considered and supported for women who are healthy, who have had a spontaneous labor in birth, regardless of the birthplace setting. So they're saying, yep, if you're in hospital, give it a go. Like, you know, birth physiology can be very robust. Like it's incredible. And, you know, Rachel Reed talks about how it's mind boggling that women could actually give birth in hospital because their physiology has been so interrupted so often. But if you've had a physiological birth in hospital, feel confident that you could back yourself to have a physiological placental birth in hospital as well. Just give it a go. If you do start to bleed after the plan to have a physiological third stage, we can still give you all that medication to stop you from bleeding afterwards. So the medication that they give to prevent you from bleeding is actually the same that we use to treat a postpartum hemorrhage. So why not wait? And I'll talk about the Cochrane review on it There was one in 2019. You're a midwife out there and you want to help support a physiological placental birth and you're working in a hospital. So home birth midwives, they've nailed this. We know. They know. Here I'm talking to midwives who work in hospitals or home birth programs like
[26:43] through a hospital service or birth centers. And you think, man, I would really love to help support a physiological birth.
[26:48] Here are just a few basics of supporting physiological placental birth. Okay, so firstly, the baby has come out. Immediately, the baby should go skin to skin with the woman and there should be an attempt to silence and quiet the room. Lights off, blankets around the woman and baby.
[27:12] Preferably, the woman should be in a more upright position, so not lying flat on her back or immediately on her side. So on knees or sitting upright in the bed if possible. And then don't interrupt that process. Try to say as few words as possible. There's no need to congratulate them on their baby, to find out what the sex is, to tell them how good a job she did. Just back away. Don't say a word. You want to make sure that the oxytocin flow that she's about to get is going to be uninterrupted by her having to think about anything, her having to respond, her having to move her gaze away from her baby or her partner. So you want to really support that whole family unit to just really hone in and concentrate on the baby, And then you don't pull on the cord, don't touch the woman's belly. The only thing I think would be a wise thing to do is to just unobtrusively observe any for any vaginal blood loss. So if the woman is gushing blood, yes, intervene. That's our opportunity to provide medical care that could save her from a catastrophic postpartum hemorrhage. So then once that's happened, what usually happens is the baby will come out and there'll be a little break in contractions. There'll be a complete state of bliss for the parents of which you need to stay right out of. Don't you be involved in that blissful state.
[28:36] And then the woman will start to feel contractions again. That's a great sign that the uterus is starting to act to bring the placenta out. If the baby's starting to root at the woman's breast, you can just gently say, yeah, you know, put the baby at your nipple. If the baby latches, that's going to facilitate the whole placental birth process. And certainly if it's taken a while, strategies to help with physiological placental birth would be to latch the baby.
[29:04] And get in a more upright birth position and the toilet is a beautiful place to birth a placenta too in terms of being able to release pelvic floor muscles and relax onto that. And if the woman is going to sit on the toilet, lift the toilet seat, put a towel over the whole thing and put the toilet seat back down so when the placenta is born, it falls into this towel hammock, And she'll need support, like physical support from either her partner or you to move around after birth. Like your legs just suddenly stop working after you have a baby. So then that's all happening. And then don't pull the cord. Don't touch the cord. Don't clamp the cord. Don't cut the cord. An intact cord is important at that point to facilitate that physiology. And then what will happen is, is the placenta will start to move out and be born. It looks the same way as if you were pulling on it. And if the placenta comes and the membranes are still trailing and the woman's sitting on the toilet, for example, you can suggest that they just very slowly stand to kind of glide the membranes out. You can twist the placenta where it sits and then just use that as the very gentle traction to bring the membranes out.
[30:19] The woman can do a few coughs, which sometimes just releases the membranes to come loose. But if the membranes are still in there and there's tension on them, I would not recommend pulling the membranes because if they tear, then you've got retained membranes. But I have in the past also, you can clamp them with the little mini forceps and kind of wiggle them back and forth, not pulling, like wiggle back and forth, right to left.
[30:49] Applying very gentle traction to help it move out through the cervix. So that's a few strategies for membranes that are trailing in there. You're more likely to have a fully intact, not rugged membranes and placenta with physiological third stage. So give it a go. Moving to the toilet, moving on to a birth stool or a bedpan or something like that can just help the women get the gravity they need to bring the placenta out.
[31:18] I do find them a bit more challenging in a water just because of the amazing support that the water offers.
[31:25] So that's a very quick rundown of how to facilitate a physiological placental birth. So we might just briefly talk about what does placental birth usually look like though for women. If you're giving birth in hospital and you're a hospital-based midwife, you'll be very, very familiar with active management. Most women in hospital will be given actively managed third stage as a routine care nobody would probably ask you do you want to wait for your placenta to come or do you want to have the injection they'll assume that you're having the injection so you'd have to actively say i'm planning a physiological third stage if you want if you don't want to have the injection the consent process for giving the oxytocin injection and in australia it's called syntocinon in America they call it pitocin so if you're hearing any American content and you hear pitocin think syntocinon that's the artificial oxytocin they usually give 10 units of it and it is injected into your thigh muscle so it's a needle and then they'll so they'll give that they'll potentially wait a minute or so to see that you've got a big strong contraction or that the cord is starting to lengthen or that there's a little bit of a gush of blood which is what we call signs of placental separation.
[32:44] And then the midwife or doctor will apply a clamp and apply what we call controlled cord traction. So it's a gradual traction on the cord, which will then bring the placenta out.
[32:58] For actively managed placental birth, once the baby's out, the injection is given and usually your placenta's out within five minutes or so of having had your baby. And you may or may not realize what's happened.
[33:12] If you didn't know what they did, you had active management because if you had physiological management, you would know because you weren't heavily involved in the process. So at the end of active management, after they've given the injection and they've pulled out the placenta, there is a step where the midwife will approximately find your belly button and push in and push down on your uterus. And the idea is that they want to push out any blood clots that are building up in there. And so some midwives just really push and women are screaming in agony at this process. You don't do it with physiological placental birth, by the way. If the woman's had a physiological birth, so if you're not used to doing physiological placental birth and the placenta's come out by itself, we never ever actually rub or push the fundus. There's a difference between feeling if the fundus is firm. So if you're touching and you can feel that there's a big firm uterus there and you're just very gently checking, that's one thing. But fundal massage, what like actually pushing down on the fundus, I don't do it. I mean, we check the fundus to see if it's firm, of course, but fundal massage is a treatment in my books. And we should also say too, there's a variety of techniques with active management and things are kind of changing. It used to be the rule that if you did active management, you needed to do all of active management.
[34:32] And if you did physiological placental birth, you had to do all the physiological placental birth. But there is some research talking about mixing the two techniques. So, for example, giving oxytocin and still relying on maternal effort and not doing the controlled cord traction. There's research around not clamping and cutting the cord for active management. So there's a whole lot of other things that they're exploring, like how much of active management can we get rid of before it.
[34:59] The risk of PPH increases in their mind. So that's active management. And we do have research from Cochrane. So Bea and I always talk about the Cochrane Database of Systematic Reviews, which draws together existing research to try and pull it together and making overall conclusions. So Cochrane's considered really good quality. They have done an updated version of active management versus expectant management of the third stage. And this is done in 2019. So they start off by saying that active management is done, it was introduced to try and reduce postpartum hemorrhage, which we have to say too is it's an issue in low-income countries. So when we're looking at stats, if the research was done in a low-income country or a medium-income country, but you're in a high-income country and in Australia, we are in a high-income country.
[35:57] Then you cannot apply any of those stats and outcomes or management to your context. So I've heard doctors talk to women about how women die in Africa. How women die in Africa has nothing to do with how women die in high-income countries with adequate access to medical care. We kind of need to forget about the idea about, you know, well, if we didn't do anything, everyone would die of PPH. Well, maybe malnourished women who don't have access to good care might, but not in high income countries. So they included eight studies in this research paper and there was 8,892 women. The studies were all undertaken in hospitals. Seven of them were in higher income countries and one was in a low income country. So then I'm not going to bore you with all the details, but they said that although the data appeared to show that active management reduced the risk of severe PPH, so that's bleeding greater than a thousand mils at the time of birth, they're uncertain of if this finding is because of the very low quality evidence. So they said while they found eight studies.
[37:14] All of the studies were of very low quality. So active management may reduce the incidence of blood loss following birth, but we have to consider that active management has potential harms and risks, including postnatal hypertension, so high blood pressure.
[37:34] Pain, and return to hospital due to bleeding. So that's another thing that they have found is that physiological placental birth. Overall, if you consider the woman's postpartum blood loss up to six weeks, women who have a physiological third stage have less bleeding over the six weeks than of women who had management with oxytocin at birth. They actually tend to bleed more postnatally when they've left the hospital compared to women who had a physiological third stage. So overall, we'll lose more blood if you've had active management. So the Cochrane said, we must emphasize that this review only has a small number of studies with small number of participants and the quality of evidence is low or very low. So we've instituted active management as a strategy for reducing postpartum hemorrhage with very low quality evidence. We can't be sure, there's no way from the current evidence that we can be sure that our management of the third stage is actually reducing postpartum hemorrhage because it hasn't been properly studied.
[38:45] And I think what also could be a factor here is that you've given artificial oxytocin in a moment where we're supposed to be relying on our body's own internal oxytocin. So our own internal oxytocin that we make is made in your brain and travels through your body. And so your brain benefits from that oxytocin. Artificial oxytocin goes into your body and can't cross into your brain. So you don't get the same effects. And then your body starts to potentially alter its own production of oxytocin in the presence of artificial oxytocin. So we, you know, not only could you be potentially robbed of the experience, but the hormonal benefit of a physiological process.
[39:31] And if you listen to the Sarah Buckley episode that we had about filling hormonal gaps, you can recover. We talk about being able to fill the hormonal gaps that are left by interfered with birth So go back in the episodes, check out the one with Sarah Buckley about hormones of labor and we talk in there about filling hormonal gaps. So it's not all lost. We can recover.
[39:53] I want to have a quick chat to women about placental birth during cesarean section. So, you know, we mentioned earlier in this episode about manual removal of the placenta, how that you can actually, with your hand, physically shear the placenta off the inside of a woman's uterus. So if your baby's been born by a cesarean section, first your baby will come out and it's still attached to the cord and usually they will immediately cut that cord and the baby's separated from the placenta and then they'll do a manual removal of the placenta through that cesarean wound and bring it out. So it happens almost immediately after the baby's born. If you want to change that story and that process, it is actually absolutely possible. I've had clients who've required cesarean sections for very legitimate medical reasons.
[40:46] And so we've sought out ways that you can actually not interrupt that placental birth process as much as possible. So some things you can do. If this is a non-emergency cesarean section and you've got an opportunity to talk to the team who are going to be assisting this cesarean section and bringing your baby out that way, you can ask for delayed cord clamping after a cesarean section. I've seen it done. I've seen doctors explore how to do it safely.
[41:15] One of the things that clinicians really worry about is that feeders are super cold and babies have trouble regulating their temperature when they're first born. And that's one of the important things about bringing them skin to skin and keeping them in blankets and keeping them warm after birth.
[41:29] So if you want the baby not to be detached from the placenta immediately after the birth and you want a few minutes of delayed cord clamping where the cord stays attached to the placenta, you can ask them to please. So if you're positioned, you'll be positioned lying down on the surgical bed. When you first get into position to have that caesarean, slightly part your legs in a way that when the baby comes out, they could actually nestle the baby in between your legs on the operating table. And that's a little bit of a way of kind of creating a little bit of warmth and a cocoon for the baby. If you want to wait a few minutes for the cord, any time extra that you can give the baby attached to its cord is better than immediate cord clamping. Even one minute or two minutes or maybe if you have a very, you know, an obstetrician super keen on giving you your wishes, three or four minutes of the baby being attached to the cord is going to allow the baby to somehow participate in how much blood it will take from its placenta before it's cut. If that's not possible and they say, no, we need to cut it immediately, tell them you want to have a lotus birth. And what that means is that the baby stays attached to its placenta long-term until days and days and days until the cord comes off by itself.
[42:55] If you tell them, I'm planning a lotus birth, do not cut the cord. They could detach the placenta from your uterus while the cord is still attached to your baby. And obviously, this relies on your baby being well when it's born. If your baby comes out due to an emergency cesarean that was done because your baby was exhibiting signs of distress, and then your baby comes out and is actually struggling with transitioning to life, it may be a better option to cut the cord and have emergency care with a pediatrician. But if your baby comes out and is screaming and pink and healthy and all of the fears that led to the cesarean section birth never actually eventuated and you're well yourself.
[43:39] Why would we not wait a few minutes before cutting the cord? So these things could be done to savor that birth process and placental birth to benefit both woman and baby and then ask to take your placenta home and you can look at your placenta and you can touch it and you can still interact with
[44:01] it even though you didn't yourself give birth to it. This episode has been all about giving birth to your placenta in all the different ways and if you want to read in full any of the articles that we've spoken about today. Join the mailing list and every single week I get emails from people saying, if I join the mailing list, how do I get access to previous episodes content? If you join the mailing list, every Monday you'll get an email and there's a button in that email that takes you to a brand master huge folder, all of the content from all previous episodes so you You won't miss out on anything ever.
[44:39] To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com. And to support the work of this podcast, wear The Rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, at MelanietheMidwife on socials and the show at The Great Birth Rebellion. All the details are in the show notes.
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