The third stage and fetal adaptation

Abstract

The modern western management of the third stage consists of a series of interlocking interventions which are applied so routinely that many obstetricians now regard them as ‘normal’. This management had its roots only 300 years ago when the dorsal position for delivery and cord traction were first introduced in France¹. Now, once the baby has been delivered, the cord is divided with scissors between double clamps. Often triple clamps are used in order to ensure the availability of umbilical arterial and venous blood samples for acid-base and blood gas analysis. This division of the cord frees the infant for transfer to the resuscitation area, where all too often he or she is placed in the disadvantageous head-down position^2,3. Meanwhile, in most developed countries, the third stage is usually managed actively⁴. An oxytocic agent, usually syntometrine, is given as the anterior shoulder delivers and, once the uterus is contracting, steady traction is exerted on the umbilical cord, while the free hand holds the uterus out of the pelvis. The aim of all these interventions is to reduce the risk of postpartum haemorrhage and retained placenta. Yet the fact remains that significant postpartum haemorrhage (> 500 ml) is commonly reported in 2–8% of hospital deliveries⁵ and manual removal of the placenta in at least 1–2% of all cases.