The birth of the placenta. It accompanies every birth. Usually it comes naturally, sometimes it has to be assisted. How does it work and why is it sometimes necessary to intervene?
Bleeding after birth, sometimes caused by the placenta, can have serious consequences. While mother and child meet for the first time, a lot is happening inside the woman’s body.
The physiological birth of the placenta
The birth of the placenta is part of a complex process that starts before the baby is born. The hormone oxytocin plays an important role in this process. On the one hand, oxytocin supports the elasticity of the uterus: it helps to increase and decrease it during and after pregnancy. On the other hand, oxytocin causes the uterus to contract more and more regularly during labour – this is how contractions occur.
The separation of the placenta
“Smell, touch (skin to skin), sound of voice, taste and movements help: the baby sneaks over the mother’s belly looking for the breast, its feet stimulate the uterus to contract.”
After the baby is born there is usually some rest first. The last remaining blood from the placenta flows through the umbilical cord to the baby and the baby starts to breathe on its own. This makes the placenta emptier and smaller. If mother and child are not disturbed during this period, the contact between them will cause the oxytocin to rise again, causing the uterus to contract again. Smell, touch (skin to skin), sound of voice, taste and movements help: the baby sneaks over the mother’s belly looking for the breast, its feet stimulate the uterus to contract. This also happens when the baby licks and drinks from the breast.
The placenta is compressed by the contraction of the uterus. The remaining blood flows back to the endometrium. The blood vessels that previously fed the placenta constrict. This causes the placenta to detach and a blood clot forms behind it. For some women this process is fast, for others it takes longer. Disturbing a a woman at any time during labour can lead to the labour being delayed, the birth of the placenta can be more difficult if mother and child are disturbed during this process. This can lead to complications, as adrenaline – the hormone produced in stressful situations – counteracts the action of oxytocin.
The urge to push again
“When the woman pushes again, the placenta slides out of her body. This usually requires little effort.”
Due to the strong contractions, the overlying sides of the uterus face each other. In this way, they close the remaining open blood vessels and prevent further bleeding. By increasing the activity in the blood clotting system, the clot formation in the ruptured blood vessels is maximised.
At this point in the process, the mother may notice that she begins to lose some blood. The umbilical cord also moves further out as the placenta begins to fall. The cervix remains open during this process and when the woman sits or stands upright, the placenta experiences little resistance and falls into the vagina. When the woman pushes again, the placenta slides out of her body. This usually requires little effort.
When the placenta is not born spontaneously
The birth of the placenta usually takes place within an hour. It may take longer, but many midwives and doctors will advise and/or take mild action after a while to prevent possible haemorrhage. For instance, they will ask you to change your position: from side-lying to squatting, stand up straight or empty your bladder. This will allow gravity to cooperate and the placenta to be born on its own after all.
What can also help during this process is to stimulate the release of natural oxytocin in the body. This can be done by providing comfort for the new mother, offering warmth and rest and avoiding stress. In addition to the above-mentioned skin-to-skin contact with the baby trying to drink from the breast, the loving closeness of the partner can also help these hormones flow.
When blood loss occurs during this period, the midwife can also feel the uterus. She does this by putting her hand at the level of your belly button. Does it feel hard or soft? When a uterus contracts well, it will have a hard feel. Good uterine activity is important for the birth of the placenta and to prevent bleeding. In fact, inability to contract properly is the main cause of postpartum haemorrhage. (Damage to the perineum or cervix can also cause bleeding and very occasionally a clotting disorder is the problem).
There are two main reasons for lower uterine activity after your baby is born:
(there are others but in this article we will only discuss the most common ones)
- When the hormone flow is interrupted or disturbed during or after birth, the uterus will not contract properly afterwards. This may be due to the administration of artificial oxytocin during labour (e.g. to speed it up). As a result, the oxytocin you normally produce yourself will no longer have a chance. Also, any adrenaline released during stress suppresses the oxytocin flow.
- There may be a mechanical problem that prevents the uterus from contracting: a full bladder may be in the way, or a retained piece of the placenta or a blood clot.
Most bleeding occurs after the placenta is born. But it also happens that there is heavy bleeding while the placenta is still in the uterus. Bleeding may also occur after a Caesarean section.
When is intervention in the birth of the placenta required?
If the placenta has not been born by one hour or if there is bleeding before the placenta is born, intervention is usually carried out. This is what we call ‘active policy’.
“Syntocinon functions differently from the body’s own oxytocin, as it is released into the bloodstream at a constant dose rather than in waves.“
When the placenta does not come naturally or there is blood loss due to reduced uterine activity, the midwife or doctor will administer syntocinon. Syntocinon is the synthetic form of oxytocin. This medicine is used primarily for introduction, acceleration of labour and/or birth of the placenta. Syntocinon functions differently from the body’s own oxytocin, as it is released into the bloodstream at a constant dose rather than in waves.
When syntocinon is used to actively assist the birth of the placenta, it attempts to mimic the physiology described above by helping the uterus to contract. Usually, syntocinon is administered via a syringe into the muscle after the baby is born. The umbilical cord is then cut and the placenta is usually extracted by controlled pulling of the umbilical cord.
Cutting the umbilical cord and the size of the placenta
Much is now known about the risks of clamping the umbilical cord quickly . It is strongly recommended to delay clamping the umbilical cord until it has stopped pulsing, so that the baby gets all the blood that is provided for him. Most midwives therefore wait some time before clamping the umbilical cord. It is safe to wait to administer syntocinon until the umbilical cord has stopped pulsing, because studies show that there is no difference between the effect when syntocinon is administered before or after the placenta is born.
If the umbilical cord is clamped prematurely, some of the baby’s blood remains stuck in the placenta. This makes the placenta larger and bulkier and therefore more difficult to get out. Many midwives and doctors therefore leave the umbilical cord hanging from the vagina unclamped and allow the blood to drain before they deliver the placenta.
The active policy often (but not always) results in a faster birth of the placenta than the choice for the physiological or wait-and-see policy. It is therefore understandable that certain hospitals choose to intervene frequently and quickly with the birth of the placenta. After all, the sooner the placenta arrives, the less stress there will be about a possible haemorrhage. In addition, women in hospital are more likely to be disturbed during labour and birth, which means that the placenta will more often not be born spontaneously.
Depending on the course of the labour and the birth, there are therefore two types of policy around the birth of the placenta:
Passive policy (after a physiological birth)
After childbirth, the woman sits upright supported by her baby. The midwife(s) keep an eye on both in case of possible discomfort. The umbilical cord should preferably remain intact, at least until it is beaten out. It is avoided that mother and child are disturbed during this period.
If there are any contractions, the woman can assume a different position / sit on the birthing stool / push along / blow on her hand…
If there are no contractions and as long as there is no blood loss, you can wait until one hour after the birth.
If there are indications that the placenta will not come out on its own or if there is bleeding, the active policy can be started.
Active policy (after a non-physiological birth)
The umbilical cord is more often clamped prematurely, while it has not finished beating.
Syntocinon is given a few to thirty minutes after delivery.
The placenta is removed by controlled traction on the umbilical cord.
An interesting study by Nove et al (2012) compared the number of bleedings between planned hospital births versus planned home births. This study showed that women who planned to give birth at home had fewer bleedings, even if they had to be transferred to hospital during labour or after delivery. The authors concluded that women and their partners should be made aware that the risk of bleeding is higher for planned hospital births than for planned home births. They also stated that further research is needed to understand why hospital births are associated with an increased risk of bleeding. It would be interesting if such research also included existing hospital protocols on episiotomies, administration of syntocinon during labour and the environment in the delivery room to learn more about their possible impact.
The most important element for a safe and effective physiological birth of the placenta is a physiological birth of the baby. This requires effective natural production of oxytocin.
The chance of this can be increased by:
- A physiological birth: no intervention during the birth process by means of induction, epidural anaesthesia, medication, instructions or complications.
- An environment that supports the production of oxytocin: privacy, dim light, warmth and comfort. Some women are perfectly capable of giving birth to their placenta amidst the chaos of their other children and noise. Probably because it is their own familiar chaos and they can relax in the midst of it.
- Undisturbed skin-to-skin contact between mother and baby: others should not touch the baby or talk to the mother. These mother-baby interactions can help with breastfeeding, but this should not be forced by ‘helping’ the baby to find the breast.
- Do not perform unnecessary actions: do not feel the uterus. No premature clamping, cutting or traction of the umbilical cord. No clinical observations or other fussing in the room that is not necessary.
- No stress or anxiety: a relaxed atmosphere in the room, a midwife who is comfortable and calm. A mother who is not stressed, because adrenaline inhibits the production of oxytocin. This is why bleeding often occurs after a complicated delivery (e.g. shoulder dystocia) or when the baby needs resuscitation.
- No pressure from the clock: Many hospitals have stricter standards than the existing birthing guidelines and have an internal policy that requires the placenta to be born within half an hour. This does not help and leads to anxiety.
An active management of the placenta reduces the risk of bleeding in deliveries where physiology is not supported and routine intervention is the norm.
– Reed, R. (2018), Why induction matters
– Reed, R. (2015) ‘An actively managed placental birth might be the best option for most women’
– Wickham, S. (2018) Birthing your placenta