The final part of labor begins after the baby is born and ends with the delivery of the placenta. Since the mother's entire attention will be on her new baby, she may not even be aware of this part of labor. There are two ways of managing this stage: naturally and actively.

Labor Facts

• The whole phase lasts for about 15 minutes, shorter in actively managed labor

• Active management involves the use of drugs, basically synthetic hormones that cause the uterus to contract and the placenta to detach from the uterine wall

• Natural or physiologically managed labor is one where the woman gives birth naturally without the aid of drugs. The uterus will contract in its own time and the expulsion of placenta will take longer. Blood loss tends to be heavier but not a concern if the mother is healthy and not anemic

• The third stage normally passes uneventfully for most; however in a few cases problems may crop up

• In most instances medical intervention becomes necessary to speed up the progress. This is termed active management. Main reason for this is to prevent hemorrhaging caused by the retained placenta

What happens next

• When the baby is about to be born, the mother will be given an injection called oxytocin either in the thigh or buttock.

• Oxytocin will help the uterus to contract. Eventually the uterus will shrink in size and become not only smaller but harder and tighter.

• The placenta will then tear away from the inner wall of the uterus with the aid of these strong contractions, and be pushed down and out from the body. Sometimes the mother will be asked to give a push or too to help in the expulsion

• At times the doctor will help by pressing on the uterus with one hand while the other hand will hold the cord tight with forceps. Simultaneously contractions also help to close off the blood vessels that were connected to the placenta to prevent the incidence of excess blood loss.

• Placenta and the membranes will slide down into a bowl for the doctor to check if the entire lot is out. If the placenta contains torn vessels this suggests that placental portions are still in there. The remnants must be removed instantly to prevent possible infection or heavy bleeding. Usually the placenta is gently scraped away from inside the uterus under general anesthetic

• The umbilical cord which is about 50 cm long will be clamped in two places to prevent blood loss then cut about 25mm from the baby's body.

• The vaginal site will be checked for tears and stitching may be necessary.

Stitches

• The vagina and perineum will be checked for tears or grazes. A small tear which is not bleeding will be left to heal on its own.

• If the cut or tear is big and involves muscle and skin, stitching becomes necessary. Local anesthetic will be given before the stitching commences; in cases of assisted delivery, the cut will be stitched immediately after the placenta has been delivered.

• The procedure involves the mother's legs being held in stirrups with the feet higher than the hips. The whole procedure will take about 20 minutes. The stitches need not be removed; they will dissolve on their own. It is important to practice hygiene and to keep the area dry to help in the healing process

The Complications

• The main complications that can arise at this stage are postnatal bleeding, retention of either entire or partial placenta and inversion of the uterus

• Postnatal hemorrhage occurs when blood loss is more than 500ml in volume. This is due to the blood vessels torn from the placenta not closing properly. It can also happen when the placenta comes away but the uterus has not stayed retracted. This happens because the uterus springs back too far due to poor muscle tone resulting after a long delivery. Poor retraction can also be due to the uterus being overstretched when housing more than one baby.

• In such instances doctor may try to massage the uterus or the mother will be given drugs to help in uterine contractions or drugs to help in clotting, whichever applicable.

• Sometimes the contractions are so forceful that the placenta remains behind. The doctor will have to remove the organ most probably through surgery. The procedure is performed under spinal anesthetic and a course of antibiotics will be given to the mother to prevent infection.

• Inversion of uterus happens only if the placenta was attached at the top of the uterus. By removing the placenta, the uterus will fold back on its own. This can also be corrected manually with the doctor pushing back the uterus into place.

Interesting Facts

• Opening the bowels will not cause the stitches to open or burst as many are inclined to believe. However straining can cause some discomfort to the area. It is therefore important to open the bowels in the first 2-3 days following the birth. Constipation is probable if you let your fear rule you and delay matters. To avoid constipation, drink lots of water, eat fresh fruits and vegetables, high fiber foods and practice pelvic floor exercises. Hold a sanitary towel against the stitches to lend some support to the area. Mild laxative may help if your doctor is in favor. An enema to help with the first bowel movement post delivery will used if all else fails.

• After delivering the placenta many women experience shivering, shaking and wobbly legs. This has been attributed to the body being deprived of the heat after the baby leaves the mother's body, fluid loss and exhaustion felt from the delivery. Shivering usually stops after 30 minutes or so, during which time the body temperature has been regularized and the internal thermostat has been reset.