Saturday, November 6, 2010

Third Stage

I am devoting this post to the third stage of labor, also known as delivery of the placenta, because my two experiences with this stage have been uncomfortable and the most recent was just downright bad.

The first time, after they put my son on my belly, it felt awkward, and I didn't really want to be with him right away. The best antidote to this apprehension probably would have been plenty of time with him just then, but alas, it could not be. They took him away almost immediately because there had been meconium (baby poop) when they broke my water and meconium when he came out, and they needed to check him out to make sure he wasn't overly stressed out. This seemed justified to me. So naturally, with the baby out of my hands, all I had to think about was the delivery of that danged placenta. I kept asking my doctor, "When is it going to come out?" Of course he couldn't answer that question, so he just assured me that it would come out, and the only thing he could do to expedite the process would be to pull on the cord but he also added, "but you don't really want me to do that, do you?" The reason he cautioned against pulling on the cord is because doing this before the placenta has separated from the uterus may cause the uterus to invert. Pressing on the belly before the placenta is delivered can cause the placenta to separated incompletely. I think both can lead to hemorrhage, and retained placental fragments can also lead to infection. He may also have known how uncomfortable it would be without an epidural.

With my most recent birth, it was even worse. Or maybe it's just because it's fresh in my memory. In any case, it was sub-par. First of all, they took my son, whom I was delighted to meet, away before I realized what was happening. I think I thought they were going to bring him right back after a minute or two, but it was a lot longer than that. And secondly, the residents attending my delivery insisted on pulling on the cord and pressing on my belly. I asked them to stop, which they did for a while, but after 30 minutes had elapsed, they got antsy again and insisted, threatening that otherwise they would have to go up there with their hands (which I'm not sure would have been much worse) to pull it out. The other thing they were trying to do at the same time was sew up a second degree perineal tear that I had sustained.

So here's the scenario: I'm shaking uncontrollably. I'm tense, because I'm freezing cold. I can barely hold my head up much less my legs and my torso. They are tugging on the cord, every bit of which I can feel. And my legs are propped up in stirrups so they can finish as quickly as possible (which I had asked them to do because I just wanted them to quit messing with me). At some point, I felt her stitching together something that I was pretty sure didn't need to be stitched together and told her so. She told me I was wrong. And my baby is somewhere else...I think in the room, but I'm not sure where...and all I can think about is being done with this awful business. Yuck.

A couple of post-delivery observations. I'm fairly certain that a chunk of my placenta came out a few days after I got home from the hospital. Also, that part that I told her I didn't think she should be sewing together? About a week later, one or two of my perineal stitches snapped, so I'm pretty sure I wasn't wrong about that. I was horrified by both of these things at first, then I was angry, and now I am just resolved for it not to happen again.

After this, I did some reading on third stage management (in the midwifery text Heart & Hands: A Midwife's Guide to Pregnancy and Birth by Elizabeth Davis) and found out the following:

Adrenaline drops immediately after delivery, and oxytocin increases. Adrenaline and oxytocin oppose one another. Oxytocin promotes bonding with your baby, breastmilk production, and (here's the kicker) delivery of the placenta! So what's at least one effective way to promote oxytocin in mom? Keep the baby with her. But guess what else? If you are cold, adrenaline remains high, "which can disrupt placental separation by opposing oxytocin" (129). Also, "A drop in adrenaline levels moments after the birth makes it difficult for [the mother] to stay upright." These are ALL the problems I experienced during third stage: freezing cold, couldn't stay upright, and tension and anxiety because they took my baby away.

"The placenta usually delivers twenty to thirty minutes after the birth, although it may take an hour or more." Maybe my placentas just take a little bit longer to deliver than others? Given the fact that my babies seem to like to stay inside for longer than other babies, maybe my placenta has a hard time letting go, too. Completely speculative, but no one else seems to have any theories about why some placentas come flying out in 10 minutes and others take their time.

Perineal tears do not need to be repaired right away. This is one thing that could have waited. I asked them to just get it over with, but I might have been able to rest and bond with my baby if I hadn't been propped up for the repair.

In the name of efficiency, they took my baby away to clean him up and do their testing, and they worked on my perineal repair while they waited for the placenta to come out. In fact, though, it may have been more efficient for them to let me hold and nurse my baby, lie down, and cover me up with blankets. This would have spurred oxytocin secretion, which would have facilitated delivery of the placenta, and they could have sewed up the perineum after the placenta had been delivered and I was comfortable again.

All of these things created a toxic combination that have given a sour foot-note to an otherwise thrilling birth experience.

Part of the problem may be that hospital care providers are unfamiliar with the sensations that a lot of women experience after delivery without an epidural. With an epidural, you probably won't feel the discomfort of the contractions after pushing the baby out, and you won't feel the discomfort of the tugging on the cord on the pressing on the belly, and you won't feel if the stitches are being done in the right place.

My last note is this. In total fairness to my providers, they were trying their best to keep me comfortable. At one point, while I was wincing from a combination of cord-pulling, perineal-stitching, still-having-contractions pain, the resident said she just couldn't bear the thought that her work (stitching the perineum) was causing me pain, so she gave me an extra shot of local anaesthetic, thinking this would solve the problem. Unfortunately, she misunderstood the source of my discomfort, so it was not effective relief. And no doubt they were anxious is because I was anxious, confused, in pain, and didn't know what I wanted or needed and was making incoherent, contradictory requests. A good friend that had a similar hospital experience asserted that care providers should know what women need and want post-delivery when they are shaky, cold, and weak. Well, they didn't; but next time, I will.


  1. Amen. I wonder if most women who deliver naturally in the hospital have similar experiences? I felt the same way as you described, Beth. Glad to know this was all a natural reaction. They did let me keep my baby in my arms and nurse her, so maybe that helped me with the placenta bit, however, it did nothing for the legs shaking out of the stirrups syndrome!

    I'm wondering if avoiding the rush to "clean up" after a birth is possible in the hospital though? Thoughts? I'm pretty sure if we get pregnant again, I'm pushing for a home birth. :)

    Your observations are insightful though, thanks for your willingness to educate!

  2. This is something I plan to ask around about...particularly how long can you go before getting stitched up (because I can always just insist that they wait for the placenta and suffer the consequences if I'm wrong about it), but I'd have to know more about how long a perineal tear can go without repair before it causes problems.

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