Placental expulsion (also called afterbirth) occurs when the placenta comes out of the birth canal after childbirth. The period from just after the baby is expelled until just after the placenta is expelled is called the third stage of labor.
The third stage of labor can be managed actively with several standard procedures, or it could be managed expectantly (also known as physiological management or passive management), the latter allowing the placenta to be expelled without medical assistance.
Although uncommon, in some cultures the placenta is kept and consumed by the mother over the weeks following the birth. This practice is termed placentophagy.
It begins as a physiological separation from the wall of the uterus. The placenta is usually expelled within 15–30 minutes of the baby being born.
Methods of active management include umbilical cord clamping, stimulation of uterine contraction and cord traction.
Umbilical cord clamping
Active management routinely involves clamping of the umbilical cord, often within seconds or minutes of birth.
Uterine contraction assists in delivering the placenta, and can be induced with medication, usually oxytocin via intramuscular injection. The use of ergometrine, on the other hand, is associated with nausea or vomiting and hypertension.
Controlled cord traction (CCT) consists of pulling on the umbilical cord while applying counter pressure to help deliver the placenta. It may be uncomfortable for the mother. Its performance requires specific training. Premature cord traction can pull the placenta before it has naturally detached from the uterine wall, resulting in hemorrhage. Controlled cord traction requires the immediate clamping of the umbilical cord.
A Cochrane review came to the results that controlled cord traction does not clearly reduce severe postpartum hemorrhage (defined as blood loss >1000 mL) but overall resulted in a small reduction in postpartum hemorrhage (defined as blood loss >500 mL) and mean blood loss. It did reduce the risk of manual placenta removal. The review concluded that use of controlled cord traction should be recommended if the care provider has the skills to administer it safely.
Manual placenta removal
Manual placenta removal is the evacuation of the placenta from the uterus by hand. It is usually carried out under anaesthesia or more rarely, under sedation and analgesia. A hand is inserted through the vagina into the uterine cavity and the placenta is detached from the uterine wall and then removed manually. A placenta that does not separate easily from the uterine surface indicates the presence of placenta accreta.
Efficacy of active management
A Cochrane database study suggests that blood loss and the risk of postpartum bleeding will be reduced in women offered active management of the third stage of labour. A summary of the Cochrane study came to the results that active management of the third stage of labour, consisting of controlled cord traction, early cord clamping plus drainage, and a prophylactic oxytocic agent, reduced postpartum haemorrhage by 500 or 1000 mL or greater, as well as related morbidities including mean blood loss, incidences of postpartum haemoglobin becoming less than 9 g/dL, blood transfusion, need for supplemental iron postpartum, and length of third stage of labour. Although active management increased adverse effects such as nausea, vomiting, and headache, women were less likely to be dissatisfied.
A retained placenta is a placenta that doesn't undergo expulsion within a normal time limit. Risks of retained placenta include hemorrhage and infection. If the placenta fails to deliver in 30 minutes in a hospital environment, manual extraction may be required if heavy ongoing bleeding occurs, and very rarely a curettage is necessary to ensure that no remnants of the placenta remain (in rare conditions with very adherent placenta, placenta accreta). However, in birth centers and attended home birth environments, it is common for licensed care providers to wait for the placenta's birth up to 2 hours in some instances.
In most mammalian species, the mother bites through the cord and consumes the placenta, primarily for the benefit of prostaglandin on the uterus after birth. This is known as placentophagy. However, it has been observed in zoology that chimpanzees apply themselves to nurturing their offspring, and keep the fetus, cord, and placenta intact until the cord dries and detaches the next day.
The placenta exists in most mammals and some reptiles. It is probably polyphyletic, having arisen separately in evolution rather than being inherited from one distant common ancestor.
- Prendiville, Walter JP; Elbourne, Diana; McDonald, Susan J; Begley, Cecily M (2000). "Active versus expectant management in the third stage of labour". Reviews (3): CD000007. doi:10.1002/14651858.CD000007. PMID 10908457.
- Hofmeyr, G Justus; Mshweshwe, Nolundi T; Gülmezoglu, A Metin; Hofmeyr, G Justus (2015). "Controlled cord traction for the third stage of labour". doi:10.1002/14651858.CD008020.pub2.
- Dehbashi S, Honarvar M, Fardi FH (July 2004). "Manual removal or spontaneous placental delivery and postcesarean endometritis and bleeding". Int J Gynaecol Obstet. 86 (1): 12–5. doi:10.1016/j.ijgo.2003.11.001. PMID 15207663.
- BMJ summary of the Cochrane group metanalysis, at Postpartum Hemorrhage: prevention by David Chelmow.
- Rens, B.; Van Der Lende, T. (2004). "Parturition in gilts: duration of farrowing, birth intervals and placenta expulsion in relation to maternal, piglet and placental traits". Theriogenology. 62 (1–2): 331–352. doi:10.1016/j.theriogenology.2003.10.008. PMID 15159125.