Placenta Delivery

Part of Midwifery and Childbirth

Managing the third stage of labor — delivery of the placenta — to prevent hemorrhage and retained tissue.

Why This Matters

The third stage of labor — from birth of the baby to delivery of the placenta — is the most dangerous stage for the mother. Postpartum hemorrhage, the leading cause of maternal death globally, primarily occurs because the uterus fails to contract adequately after placenta delivery, or because fragments of placenta remain inside and prevent the uterus from closing the blood vessels at the implantation site.

The placenta separates from the uterine wall after birth, as the uterus contracts and shrinks. Once separated, it must be delivered. If it is not delivered within about 30-60 minutes, if it is partially separated, or if fragments remain inside, hemorrhage risk rises dramatically. Retained placenta is one of the most common causes of life-threatening postpartum bleeding.

The birth attendant’s role in the third stage is: recognize when the placenta has separated, assist delivery without causing harm, inspect the placenta for completeness, and respond immediately if hemorrhage begins.

Physiological Third Stage

What happens normally:

1. Baby is born.
2. Uterus contracts, shrinks in size.
3. The placenta, now implanted on a much smaller surface, begins to shear away from the uterine wall (placental separation).
4. Blood pools behind the placenta as it separates (retroplacental bleed — a normal gush of 100-200 mL).
5. The placenta descends into the lower uterus and then the vagina.
6. The mother feels pressure or urge to push. The placenta is pushed or born.

Duration: In most cases, the placenta delivers within 30 minutes of the baby’s birth. Delivery within 5-10 minutes is common.

Signs of Placental Separation

Do not attempt to deliver the placenta before it has separated. Pulling on the cord before separation can cause partial placental tearing, uterine inversion, or umbilical cord avulsion (cord breaking, leaving placenta inside). Wait for these signs:

Signs the placenta has separated:

1. Cord lengthening: The external length of umbilical cord increases as the placenta descends from the uterine fundus toward the vagina.
2. Gush of blood: A sudden gush of dark blood from the vagina (100-200 mL) as the retroplacental blood is released.
3. Uterus rises and becomes firmer: The uterus, which was at navel level after delivery, may rise slightly and feel harder and more rounded.
4. Maternal urge to push: The woman may feel pressure or the urge to bear down as the placenta enters the vagina.

One or more of these signs together indicates separation. All three together is a strong confirmation.

Delivering the Placenta

Physiological (Passive) Management

Ask the mother to push with the next urge. In an upright position (squatting, sitting), gravity helps. The placenta usually delivers easily with a few pushes once separated.

Optimal position for placenta delivery: Squatting or semi-upright. Gravity assists. The placenta often slides out almost without effort.

Controlled Cord Traction (if needed)

If the placenta does not deliver with pushing alone, controlled cord traction can assist — but only after signs of separation are confirmed.

Technique:

1. One hand is placed on the lower abdomen, just above the pubic bone, with firm but gentle upward counter-pressure on the uterus (to prevent inversion as you pull the cord).
2. The other hand holds the cord close to the vaginal opening.
3. With the next contraction (when the uterus is contracting and firm), apply steady, firm, downward-then-outward traction on the cord.
4. The cord should not break. If resistance is high, stop and wait — the placenta may not be fully separated.
5. Guide the placenta out. Once the placenta emerges, cup it in both hands to prevent tearing the membranes — membranes tear easily and retained membrane fragments cause ongoing bleeding.

Membrane delivery: As the placenta emerges, allow the membranes to trail out slowly. Gently rotate the placenta in a circular motion as it emerges — this twists the membranes into a rope and prevents tearing. Cup them as they come.

Inspecting the Placenta

This step is mandatory. Inspect every delivered placenta for completeness.

A complete placenta looks like a thick, meaty disc approximately 20-22 cm in diameter and 2-3 cm thick. Maternal surface (the side that was against the uterus): dark red, with a “raw” cotyledon (segment) pattern. Fetal surface: smooth, shiny, with cord insertion at or near center.

Checking for completeness:

1. Hold the placenta by the cord and examine the maternal surface. The cotyledons (lobes) should form a complete disc. Any gaps, missing sections, or torn-edge appearance suggests retained placental fragments.
2. Examine the membranes. They should be largely complete — a bag surrounding the placenta. Hold the membranes up to light — holes in the membranes where vessels were suddenly cut off suggest a succenturiate lobe (an accessory placenta that may have been left inside).
3. Examine the cord insertion and the membranes near the cord for extra vessels that end abruptly (a sign of vasa previa or succenturiate lobe).

If placenta is incomplete: Retained placental fragments will cause ongoing hemorrhage. This requires manual removal of fragments from the uterus — a dangerous procedure but sometimes unavoidable. Clean hands inserted into the uterus to sweep out fragments. Very high infection risk. Use only if bleeding is severe and non-responsive to uterine massage.

After Placenta Delivery

Uterine massage: Immediately after placenta delivery, place a hand on the lower abdomen and feel the uterus. It should be firm. If it is soft or boggy, massage gently with a circular motion until it contracts firmly. A well-contracted uterus has closed the blood vessels at the placental site.

Continue monitoring: See bleeding monitoring article. First hour is highest risk. Check uterine tone every 15 minutes.

Oxytocin measures without drugs:

• Nipple stimulation — breastfeeding immediately after delivery releases endogenous oxytocin, which contracts the uterus. This is the most important natural uterine contraction stimulus.
• Uterine massage — direct stimulation causes contraction.
• Shepherd’s purse (Capsella bursa-pastoris) herb — traditional uterine tonic, may support contraction. Strong tea from the whole plant. Not a replacement for massage and breastfeeding, but a useful adjunct.

Never Pull on an Unseparated Cord

Premature cord traction before placental separation is a leading cause of uterine inversion — a life-threatening emergency. Wait for the signs of separation. Patience in the third stage prevents the most dangerous complications.