Should I have a managed or physiological third stage?

Emma Dufficy

Hospital midwife.

Your third stage of labour begins once your baby is born and ends when you deliver the placenta. You can choose to have either a physiological (or natural) third stage or an actively managed third stage.

A physiological third stage means that you wait for the placenta to be delivered naturally. After your baby's birth, your midwife will delay clamping the umbilical cord to allow oxygenated blood to pulse from the placenta to your baby.

Your uterus (womb) will contract, and the placenta will peel away from the wall of your uterus. The placenta will then drop down into your vagina, ready for you to push it out.

Breastfeeding and skin-to-skin contact with your baby stimulate contractions and may help your natural third stage along. It may be easier to push your placenta out if you are in an upright position.

Your baby's cord is usually clamped and cut after the placenta has been delivered, or when the cord has stopped pulsating. Your midwife will check the placenta and membranes to ensure they are complete and that no part has been left behind.

A managed third stage is routinely given in some hospitals. Your midwife or doctor will give you an injection in your thigh once your baby's shoulder emerges. After your baby is born, the cord will be clamped and then cut. Your midwife may advise you to have a managed third stage if your pregnancy or birth had complications.

Even if your third stage is managed, you can request a delay to when your baby's cord is clamped and cut. If this is the case, after your injection, your midwife will leave the cord until it stops pulsating.

The injection causes your uterus to contract strongly so the placenta comes away. You don't have to push during a managed third stage. Once your uterus contracts, your midwife will pull gently on the cord while pressing on your tummy above your pelvis. By pressing on your tummy, your midwife supports your uterus while she eases out the placenta.

Speed is not necessarily a reason to choose a managed third stage over a natural third stage. Both methods take a little over 10 minutes from the birth to when you deliver the placenta. But a physiological third stage may on occasion take an hour, which is why women often take the managed route.

The main advantage of a managed third stage is the lower risk of very heavy bleeding immediately after the birth. You will also be less likely to become anaemic in the days afterwards.

However, if you've had a managed third stage, there's more of a chance that you'll need to return to hospital later because of bleeding. This may be due to fragments of placenta or membrane that have been left behind when your midwife eased out the placenta.

The drugs which are used to narrow your blood vessels and stimulate contractions may unfortunately have side-effects. Ergometrine, when mixed with oxytocin to make up Syntometrine, may cause you to have:
  • high blood pressure
  • sickness and vomiting
  • strong pains
  • a greater need for pain relief

Many maternity units now use the single drug oxytocin because of this. Though this may cause fewer side effects than Syntometrine, it may be less effective at reducing blood loss.

Your baby may have a lower birth weight after a managed third stage than he would after a natural third stage, though the difference is minimal. This may be due to cutting the cord early. But rest assured your midwife will make a decision based on what is right for your health.

Your midwife or doctor will recommend you have a managed third stage if you had complications during pregnancy or labour, such as:

If you have a prolonged third stage, you're at greater risk of heavy bleeding. Your midwife will treat you for retained placenta if your physiological third stage takes longer than one hour or if your managed third stage takes longer than 30 minutes. She may also do this if you start to bleed more heavily.

If you are at a low risk of heavy bleeding, it seems that the rate of heavy bleeding will be about the same whichever method you use.

Talk to your midwife about your options for third stage labour when you write your birth plan. That way you can make your wishes clear from the outset.

Last reviewed: October 2011


This article was written using the following sources:

Begley CM, Gyte GML, Murphy DJ, et al. 2010. Active versus expectant management for women in the third stage of labour. Cochrane Database of Systematic Reviews (7):CD007412. [Accessed May 2011]


McDonald SJ, Abbott JM, Higgins SP. 2004. Prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour. Cochrane Database of Systematic Reviews. Issue 1. Art. No.: CD000201. [Accessed May 2011]

McDonald SJ, Middleton P. 2008. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews Issue 2. Art. No.: CD004074. [Accessed May 2011]


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I had a managed one but I bled terribly and had a tear on my vagina
I am amazed to read this. Birth is a natural thing, why the injection? When your baby is placed on your chest, the cord stops pulsating, it is cut, and you do not even notice your body pushes the placenta out! It is such a simple thing! By the time you look up, you are stitched and cleaned and you are all finished! With my first baby some placenta was left inside (there was a reason) and OK, taking the rest out was no dancing and I did bleed heavily. But still then, the main body of the placenta did come out on its own accord without any waiting and pain!

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