Labor and delivery: Management of the normal third stage after vaginal birth

INTRODUCTION — This topic will present a paradigm for intrapartum management of the third stage of labor (ie, time from fetal expulsion to delivery of the placenta). Our approach is based upon findings from randomized trials when available, as well as our clinical experience, data from observational studies, and expert opinion. As in the first and second stages, creating a positive childbirth experience is one of the goals of care in the third stage.

Intrapartum care in the first and second stages of normal labor is discussed separately:

●(See "Labor and delivery: Management of the normal first stage".)

●(See "Labor and delivery: Management of the normal second stage".)

Detailed discussion of specific subjects related to labor and birth and intrapartum care of complicated labor and birth are also reviewed separately in individual topic reviews on each subject (eg, abnormal progression, preterm labor, cervical ripening and induction, operative vaginal delivery, cesarean birth, malpresentation, analgesia and anesthesia, support, maternal medical/obstetric disorders, episiotomy, multiple gestation, postpartum hemorrhage).

Management of labor and delivery during the coronavirus disease 2019 (COVID-19) pandemic is reviewed separately. (See "COVID-19: Intrapartum and postpartum issues", section on 'Approach to infection control'.)

CORD SEVERANCE — The umbilical cord is typically clamped 2 to 3 centimeters (0.8 to 1.2 inches) from the umbilicus, although research evaluating the optimal distance is minimal [1]. If the cord insertion site appears abnormal, it is prudent to lengthen this distance to avoid clamping across herniated bowel in an omphalocele or umbilical hernia.

Early versus delayed cord clamping — Delayed cord clamping has newborn benefits compared with immediate cord clamping in both term and preterm births [2,3]. Near and at term, the major benefit is on newborn hematological parameters; significant favorable effects on major newborn morbidities have not been established [4]. In preterm infants, mortality is reduced [5].

Delayed cord clamping does not appear to have maternal benefits or harms. Maternal blood loss and frequency of postpartum hemorrhage are not increased compared with immediate clamping in patients undergoing cesarean or vaginal birth [2,6-8].

Almost all trials have been restricted to newborns not requiring resuscitation. Multiple gestations, congenital anomalies, placental abnormalities, alloimmunization, fetal anemia, fetal compromise, and maternal illness were exclusion criteria in many studies so the benefits and harms in these clinical settings may be different from those in singleton vigorous newborns from largely uncomplicated pregnancies [9].

Term infants — We suggest delayed cord clamping after birth of vigorous term infants. The American College of Obstetricians and Gynecologists (ACOG) [10], American Academy of Pediatrics (AAP) [11], and most other clinical practice guidelines also endorse this approach [9,12,13].

●Duration – Although the optimum amount of time before cord clamping has not been established [7], we agree with the ACOG recommendation of a delay of at least 30 to 60 seconds [10]. The 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommended deferred cord clamping for at least 60 seconds for newborns ≥34 weeks who do not require immediate resuscitation (weak recommendation, very low-certainty evidence) [9]. A 2022 guideline from the Society of Obstetricians and Gynaecologists of Canada and the Canadian Paediatric Society recommended 60 seconds for term newborns [13]. Others have suggested a two- to five-minute delay (or longer if the mother requests it) [14]; however, the benefits of an extended delay are unclear as approximately 75 percent of blood available for placenta-to-fetus transfusion is transfused in the first minute after birth [15].

●Contraindications

•Delaying cord clamping should not interfere with timely care of the newborn and should never compromise the safety of the mother or newborn. For example, it is not appropriate when the mother or newborn is unstable or when the newborn-placental circulation is not intact (eg, abruption, cord avulsion).

•Monochorionic twin pregnancy is a contraindication for delayed cord clamping because acute and large intertwin blood transfusion may occur during labor and birth, and the direction of transfusion is not predictable. (See "Twin pregnancy: Labor and delivery", section on 'Cord clamping'.) 

•Delaying cord clamping may not be appropriate in cases of fetal growth restriction with abnormal umbilical artery Doppler studies, as these newborns may already have polycythemia and hyperviscosity. Limited data in this specific population preclude a clear conclusion [16].

●Benefits and harms

•The main advantage of delayed cord clamping is higher infant iron stores at six months of age, which may be particularly advantageous when the mother has a low ferritin level or plans to breastfeed without supplementing with iron or fortified formula. Preventing or reducing the occurrence of iron deficiency in infants may have favorable long-term developmental effects, since iron deficiency has been associated with impaired neurodevelopment. (See "Anemia in pregnancy".)

•The main disadvantages of delayed cord clamping include:

-Increased risk of hyperbilirubinemia in the immediate newborn period resulting in more phototherapy.

-Increased risk of polycythemia in small for gestational age newborns.

-Reduced volume of umbilical cord blood available for harvesting stem cells; thus, the size and cell dose of collected cord blood units may not be adequate for a future hematopoietic cell transplant if cord clamping is delayed. This should be considered when cord blood collection is planned for this purpose. (See "Collection and storage of umbilical cord blood for hematopoietic cell transplantation".)

In a meta-analysis of 15 randomized trials including 3911 mothers and their infants that evaluated early versus delayed (two to three minutes after birth) cord clamping in term infants, compared with early cord clamping [2]:

•Delayed cord clamping resulted in:

-Higher neonatal hemoglobin levels at 24 to 48 hours after birth (mean difference 1.49 g/dL, 95% CI 1.21-1.78), but not on subsequent assessments

-A lower proportion of infants with iron deficiency at three to six months of age (8 versus 14 percent; risk ratio [RR] of iron deficiency with early clamping: 2.65, 95% CI 1.04 to 6.73)

-A 40 percent increase in newborns needing phototherapy for jaundice (4.36 versus 2.74 percent; RR of phototherapy with early clamping: 0.62, 95% CI 0.41-0.96)

The only randomized clinical trial that assessed long-term developmental effects of delayed versus early cord clamping reported a possible benefit in some neurodevelopmental outcomes at four years of age, particularly in males, and no harmful effects [17].

Preterm infants — We recommend delayed cord clamping in vigorous preterm infants.

●Duration – We delay cord clamping for at least 30 to 60 seconds as approximately 75 percent of blood available for placenta-to-fetus transfusion is transfused in the first minute after birth [15]. There is no consensus on the optimal duration to delay clamping.

•ACOG recommends a delay of at least 30 to 60 seconds after birth in both vigorous term and preterm infants [10].

•The 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommended deferred cord clamping for at least 30 seconds for newborns <34 weeks who do not require immediate resuscitation (weak recommendation, moderate-certainty evidence) [9].

•A 2022 guideline from the Society of Obstetricians and Gynaecologists of Canada and the Canadian Paediatric Society recommended a minimum of 30 seconds and preferably 60 to 120 seconds for preterm newborns [13].

•A 2023 network meta-analysis with individual participant data found that a long delay (≥120 seconds) significantly reduced mortality before discharge compared with immediate clamping in preterm births (OR 0.31, 95% CI 0.11-0.80) in preterm births [18]. Mortality before discharge was also lower for short delays of 15 to <45 seconds (OR 0.82, 95% CI 0.41-1.73) and medium delays of 45 to <120 seconds (OR 0.76, 95% CI 0.48-1.39), but the confidence intervals crossed 1.0 with these delays. Limitations of the analysis preclude making a confident conclusion that a long delay (≥120 seconds) is optimal. For example, many trials did not collect data on intervention adherence and adherence was often low in those that did, no trials directly compared medium delay with long delay, and interventions such as active resuscitation before cord clamping differed among trials.

●Benefits and harms – In preterm infants, an advantage of delayed cord clamping is that it provides more time for the physiologic transition from fetal to newborn life. During this transition, clamping the cord too quickly, ie, before initiation of spontaneous respirations (mean onset of respiration is 10±15 seconds after expulsion [19]) appears to adversely affect cardiovascular hemodynamics (decreased cardiac output), likely due to removal of umbilical venous return before dilation of the pulmonary vascular bed [20-23]. Lung aeration triggers an increase in pulmonary blood flow, which supplies most of the preload to the left ventricle; if cord clamping precedes onset of respiration, ventricular preload, cardiac output, and systemic blood pressure fall because the loss of umbilical venous return is not balanced by an increase in pulmonary venous return [23,24]. Another advantage of delaying cord clamping is that it increases the volume of placental blood transfused to the fetus and thereby increases neonatal blood volume, improves neonatal and infant iron stores, and decreases neonatal and infant anemia.

The physiologic changes off delayed cord clamping may be particularly important for newborns who are apneic and hypoxic at birth (ie, nonvigorous newborns), in whom the increase in cardiac output counteracts the effects of hypoxemia, prevents large swings in arterial pressure and flow, and thus helps to stabilize the newborn. The safety, efficacy, and appropriate technique for delayed cord clamping in preterm newborns who are not vigorous requires further study before it can be recommended.

Although a benefit has not been demonstrated consistently, delayed cord clamping is unlikely to be harmful in preterm infants, even those who are small for gestational age [25]. Differences among populations and physician judgment as to whether it was safe to delay cord clamping likely impacted the precision of the following data.

•<37 weeks: In an individual participant data meta-analysis of randomized trials of delayed versus immediate cord clamping at preterm birth, delayed cord clamping (>30 seconds) [5]:  

-Reduced death before discharge (6.0 versus 8.2 percent, OR 0.68, 95% CI 0.51–0.91; high-certainty evidence, 20 trials, 3260 participants, 232 deaths). The effect was consistent across subgroups including gestational age at birth, birth route, multiple birth, sex, trial year, and perinatal mortality.

-Reduced the need for blood transfusion in neonates <32 weeks (OR 0.59, 95% CI 0.47-0.73).

Limitations of the analysis included lack of individual participant data in 16 of 48 trials (19 percent of infants) in the systematic review; many trials excluded at-risk populations (eg, multiple gestation and infants requiring resuscitation) and most were performed in high-resource countries, limiting generalizability; low adherence to deferred clamping in many trials; and lack of data on morbidity.

•<34 weeks: In a meta-analysis of trials comparing early (<30 seconds) cord clamping, delayed (≥30 seconds or based on physiologic parameters) cord clamping, and cord milking of newborns <34 weeks (42 trials, 5772 infants), avoiding early cord clamping improved hematologic outcomes [26]. However, there were no statistically significant differences in rates of survival-to-discharge or major morbidity among the groups.

•<28 weeks: When only extremely preterm infants (≤28 weeks) are considered, a randomized trial (3116 infants) found that placental transfusion (delayed cord clamping or cord milking) did not significantly affect the composite outcome of mortality or major morbidity by 36 weeks postmenstrual age (PMA, adjusted odds ratio [aOR] 1.26, 95% CI 0.95-1.66 [27]. However, there was a reduction in mortality (aOR 0.71, 95% CI 0.55-0.92) and treatment for hypotension in the first 24 postnatal hours (aOR 0.66, 95% CI 0.53-0.82). (Note: PMA is the time period from the first day of the mother's last menstrual period to the present, thus including both prenatal and postnatal weeks.)

Cord milking — We do not milk or strip the umbilical cord; however, some experts consider this practice an alternative to delayed clamping for enhancing blood transfusion, especially when delayed clamping is not feasible. Depending on technique, cord milking may be more efficient than delayed cord clamping for improving neonatal blood volume. A randomized trial in preterm infants found that milking the accessible length of the cord four times at a speed of 20 cm/2 seconds was equivalent to delaying cord clamping for 30 seconds [28].

●Contraindications – Cord clamping should not be unnecessarily delayed to milk the cord in situations where immediate pediatric assistance is needed, such as thick meconium or neonatal depression. Also, it should not be performed if cord blood collection is planned. The 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommended against intact-cord milking for newborns <28 weeks, given a possible increase in severe IVH (weak recommendation, very low–certainty evidence) [9].

●Benefits and harms – Cord milking, like delayed cord clamping, may help stabilize blood pressure and increase urine output in preterm infants and nonvigorous infants, and thus reduce mortality [29-32]. However, a major concern is that, in contrast to the passive/physiologic blood flow of delayed cord clamping, actively milking the cord may result in rapid flow of blood to an immature infant, which could be harmful.

•In an individual participant data meta-analysis of randomized trials of umbilical cord clamping and milking strategies at preterm birth <37 weeks [5]:

-Any cord milking resulted in a similar rate of mortality to discharge as delayed cord clamping (OR 0.95, 95% CI 0.59-1.53; low certainty, 12 trials, 1303 participants, 93 deaths). Although it reduced mortality to discharge compared with immediate cord clamping, the reduction was not statistically significant (OR 0.73, 95% CI 0.44-1.20; low certainty, 18 trials, 1561 participants, 74 deaths).

-Any cord milking did not clearly increase the risk of intraventricular hemorrhage compared with delayed cord clamping (<32 weeks: OR 1.04, 95% CI 0.75-1.44, low certainty; ≥32 weeks: OR 1.62, 95% CI 0.47-5.50, very low certainty).

Interpretation of available data is limited by the heterogeneity of milking techniques used in the trials, differences in gestational age, and the lack of information about cord milking in extremely preterm newborns (<28 weeks). However, there appears to be equipoise between delayed cord clamping and cord milking in the overall population of vigorous preterm newborns. In term newborns, data on cord milking versus delayed cord clamping are limited and insufficient to make a conclusion regarding the best approach [33].

Physiological cord clamping — Physiological cord clamping (PCC) is a form of delayed cord clamping in which the time the cord is clamped is based on physiological parameters such as onset of respirations and cessation of cord pulsations rather than at a fixed time point. The cord generally remains unclamped for a longer period of time with PCC compared with nonphysiological delayed cord clamping (three to five minutes versus 30 to 60 seconds [34]). Because some newborns may need intervention before their pulmonary and hemodynamic transitions to extrauterine life have been completed, resuscitation tables have been developed that enable a full standard of care for stabilization of newborns with an intact umbilical cord [34].

In the first randomized trial of PCC versus delayed cord clamping (at 30 to 60 seconds after birth) in preterm infants <32 weeks, the PCC group needed less time to reach stability (mean time 5:54±2:27 versus 7:07±2:54 minutes; mean difference -1:19 minutes, 95% CI -3.04 to 0.27) [35]. Stability was defined as regular spontaneous breathing, heart rate ≥100 bpm and oxygen saturation (SpO₂) >90 percent while on fraction of inspired oxygen (FiO₂) <0.40, at which time the cord was clamped. Although the investigators used a specialized resuscitation table designed to provide full standard care (eg, respiratory management, heat loss prevention) while the cord remained intact, 4 of 20 infants in the PCC group had moderate hypothermia compared with 1 of 17 infants in the delayed clamping group.

A meta-analysis by the 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care found an uncertain survival benefit with PCC compared with delayed cord clamping in late preterm and term newborns [9]. The risk of neonatal mortality with delayed cord clamping was RR 5.00 (95% CI 0.24-103.4): 12 per 1000 more newborns died (range 10 fewer to 30 more per 1000 newborns) when delayed cord clamping was intended compared with when PCC was intended, but the data were based on a small single trial.

Umbilical nonseverance — We strongly discourage this practice. In umbilical nonseverance (also called Lotus birth), the umbilical cord is not clamped and cut [36-39]. The cord and placenta remain attached to the newborn until the cord naturally detaches from the umbilicus, which typically takes 3 to 10 days.

Proponents of this practice, which is uncommon and mostly done in home births, believe it is less stressful for the newborn, leads to a more robust immune system, and promotes maternal-infant bonding. There is no proven medical benefit and no biological plausibility that would suggest medical benefit [40]. It is neither natural nor physiologic since blood flow in the cord stops 5 to 10 minutes after birth. Some disadvantages include the odor associated with placental necrosis, hygienic and infection issues, and inability to perform histologic examination, if indicated.

Data are limited to a few case reports, with at least two describing serious neonatal infections that may have been related to the practice [41,42].

CORD BLOOD — Cord blood is obtained for a variety of reasons:

●ABO, RhD, diagnostic studies – Cord blood may be tested for ABO and RhD type and/or to further evaluate a disorder suspected in utero. Cord blood collected for diagnostic purposes is usually obtained by allowing blood to drain from the cut end into a glass tube prior to delivery of the placenta, if possible.

It should be noted, however, that newborn screening programs typically obtain blood from a heel stick obtained as close to hospital discharge as possible to permit the maximum accumulation of abnormal compounds in the infant's blood and the best chance of obtaining a positive result if disease is present. (See "Overview of newborn screening".)

●Acid-base analysis – When indicated, fetal blood for acid-base analysis is collected from an umbilical artery using a needle and syringe to minimize exposure to air and avoid mixing of arterial and venous blood. The test is performed after any delivery in which a fetal metabolic abnormality is suspected. Some clinical scenarios where such testing is indicated include, but are not limited to, any delivery with one or more of the following:

•Low Apgar score (0 to 3 at ≥5 minutes)

•Category III fetal heart rate pattern

•Assisted vaginal delivery (vacuum, forceps) performed for nonreassuring fetal status

The procedure for collection and interpretation of results are described separately. (See "Umbilical cord blood acid-base analysis at delivery", section on 'Technique' and "Umbilical cord blood acid-base analysis at delivery", section on 'Test results'.)

●Cord blood banking – Collection of cord blood for banking can be performed with a needle and syringe before or after delivery of the placenta. Delayed cord clamping significantly reduces the volume of cells available for cord blood donation and may prevent adequate collection. The procedure for collection of umbilical cord blood for banking is reviewed separately. (See "Collection and storage of umbilical cord blood for hematopoietic cell transplantation".)

PLACENTAL DRAINAGE — After the cord has been cut, there is no clinical benefit to allowing the placenta to drain any residual blood, although small differences in the length of the third stage and average blood loss were described in randomized trials before the era of delayed cord clamping [43]. Placental drainage does not reduce the incidence of postpartum hemorrhage or retained placenta.

Draining the placenta passively or actively prior to extraction may result in less fetomaternal bleeding. However, available data are sparse and discordant and whether a reduction in clinical sequelae (ie, alloimmunization) occurs has not been evaluated [44,45].

PLACENTAL SEPARATION AND EXPULSION

Overview — Myometrial thickening after birth of the infant leads to substantial reduction in uterine surface area, resulting in shearing forces at the placental attachment site and placental separation. This process generally begins at the lower pole of the placental margin and progresses along adjacent sites of placental attachment. A "wave of separation" spreads upward so that the uppermost part of the placenta detaches last [46,47]. Signs of placental separation include a gush of blood, lengthening of the umbilical cord, and anterior-cephalad movement of the uterine fundus, which becomes firmer and globular after the placenta detaches.

Placental expulsion follows separation as a result of a combination of events including spontaneous uterine contractions, downward pressure from the developing retroplacental hematoma, and an increase in maternal intra-abdominal pressure.

Length of the third stage — The normal third stage is generally considered ≤30 minutes between birth of the infant and expulsion of the placenta, but there is no universally accepted criterion. In two large series of consecutive deliveries, the average length was five to six minutes, 90 percent of placentas were delivered within 15 minutes, and 97 percent were delivered within 30 minutes of birth [48,49].

Gestational age is the major factor affecting the length of the third stage: Preterm births are associated with a longer third stage than term births [48-51].

Management of a prolonged third stage (ie, absence of placental expulsion [retained placenta] within 30 minutes) is reviewed separately. (See "Retained placenta after vaginal birth".)

Active management — We actively manage the third stage because active management reduced the risk of severe postpartum blood loss and blood transfusion compared with expectant (physiologic) management in randomized trials. The evidence supporting this approach is provided separately. (See "Management of the third stage of labor: Prophylactic pharmacotherapy to minimize hemorrhage", section on 'Active management'.)

Active management is a bundle of interventions including prophylactic administration of a uterotonic agent any time after delivery of the anterior shoulder and controlled traction of the clamped cut cord until the placenta spontaneously separates and is expelled. Prophylactic uterine massage is sometimes performed, but does not provide added benefit if a uterotonic drug is being administered (eg, no significant reduction in risk of postpartum hemorrhage, mean blood loss, or use of additional uterotonics) [52]. In multiple gestations, the aforementioned maneuvers are delayed until after the birth of the last fetus.

●Uterotonic agent – The uterotonic agent is the most important component of the active management bundle and oxytocin, administered intravenously or intramuscularly, is the most used agent. Dosing and evidence of efficacy, as well as other drug options, are reviewed separately. (See "Management of the third stage of labor: Prophylactic pharmacotherapy to minimize hemorrhage", section on 'Oxytocin'.)

●Controlled cord traction – Controlled cord traction facilitates separation and delivery of the placenta. In a meta-analysis of randomized trials comparing controlled cord traction with a hands-off approach, controlled cord traction resulted in a reduced need for manual removal of the placenta (risk ratio [RR] 0.70, 95% CI 0.58-0.84), as well as small statistical reductions in the duration of the third stage (three minutes), mean blood loss (10 mL), and incidence of postpartum hemorrhage (11.8 versus 12.7 percent, RR 0.93, 95% CI 0.87-0.99); the rates of severe postpartum hemorrhage, need for additional uterotonics, and blood transfusion were not statistically different [53]. Others have reported similar findings [54]. Although the benefits of controlled cord traction are small, there are no significant harms from the maneuver if performed gently without excessive traction, which can result in cord avulsion or uterine inversion.

Two maneuvers for applying cord traction have been described; we prefer the Brandt-Andrews maneuver.

•In the Brandt-Andrews maneuver, an abdominal hand secures the uterine fundus to hold it in a fixed position and prevent uterine inversion while the other hand exerts sustained downward traction on the clamped umbilical cord [55].

•In the Crede maneuver, the clamped umbilical cord is held at a fixed position with one hand while the abdominal hand grasps the uterine fundus and applies sustained cephalad traction. If the cord avulses before delivery of the placenta, we wait up to 30 minutes for spontaneous placental separation and expulsion with maternal pushing. While waiting, preparations are initiated in case manual removal of the placenta is needed. We intervene promptly if bleeding becomes heavy. (See "Retained placenta after vaginal birth", section on 'Management'.)

●Placental expulsion – As the placenta emerges from the vagina, the membranes flow behind it. Slowly rotating the placenta in circles as it is delivered or grasping the membranes with a clamp helps prevent them from tearing and possibly being retained in the uterine cavity.

●Placental examination – The placenta, umbilical cord, and fetal membranes should be systematically examined. The fetal side is assessed for any evidence of vessels coursing to the edge of the placenta and into the membranes, suggestive of a succenturiate placental lobe. The number of vessels in the cord is recorded. (See "Gross examination of the placenta".)

BLOOD LOSS — Over 90 percent of parturients receiving routine pharmacologic prophylaxis against postpartum hemorrhage have blood loss <500 mL at vaginal birth [56]. The diagnosis of excessive bleeding is preferably made using a quantitative method (eg, blood collection in drapes that are calibrated or weighed), but can be made subjectively (picture 1). It may be related to uterine atony, trauma, coagulopathy, placental abnormalities, or uterine inversion. (See "Overview of postpartum hemorrhage", section on 'Criteria for diagnosis' and "Overview of postpartum hemorrhage", section on 'Quantify blood loss' and "Overview of postpartum hemorrhage", section on 'Causes of postpartum hemorrhage'.)

Postpartum hemorrhage is a life-threatening emergency. Management is reviewed in detail separately.

●(See "Overview of postpartum hemorrhage".)

●(See "Postpartum hemorrhage: Medical and minimally invasive management".)

●(See "Postpartum hemorrhage: Management approaches requiring laparotomy".)

REPAIR OF LACERATIONS — The cervix, vagina, and perineum should be examined for evidence of birth injury. A routine rectal examination should also be considered because failure to recognize and repair an anorectal injury (mucosa and/or sphincter) can lead to serious long-term morbidity, most notably fecal incontinence. If the provider can clearly see the posterior vagina and it appears intact, a rectal examination may not be necessary; however, the provider should be aware of the possibility of an intact perineum but a "buttonhole" tear of the rectal mucosa.

A laceration can occur during any birth. The major risk factors for third- and fourth-degree perineal lacerations are nulliparity, forceps- or vacuum-assisted vaginal birth, midline episiotomy, and birth of a macrosomic newborn [57,58]. If a laceration is identified, repair should be initiated with adequate analgesia and the laceration length and position should be noted in the medical record. (See "Repair of perineal lacerations associated with childbirth".) We perform a second rectal examination after perineal repair of any laceration that is more than superficial to palpate sutures inadvertently placed through the rectal mucosa into the rectal lumen. If mucosal sutures are identified, we take down the repair and resuture, although this is probably unnecessary since there is no evidence that transmucosal stitches increase the risk of fistula formation. (See "Fecal and anal incontinence associated with pregnancy and childbirth: Counseling, evaluation, and management".)

INSTRUMENT AND SPONGE COUNTS — It is important to perform counts before and after every birth to ensure that no gauge sponges or instruments are left in the vagina. In addition to a sponge count, some institutions use a second method to confirm that no sponge remains in the patient (eg, embedding a ferrite core in all sponges and using a detector to scan the patient for a ferrite core). Clinicians can also examine the vagina for sponges at completion of the birth or choose to avoid using gauge sponges in the vagina. (See "Retained surgical sponge (gossypiboma) and other retained surgical items: Prevention and management".)

MATERNAL-NEWBORN INTERACTION

Skin-to-skin contact — In the absence of maternal or neonatal complications, a healthy term infant should be dried to minimize heat loss and given to the mother. Skin-to-skin contact helps to stabilize neonatal physiological parameters, promote exclusive breastfeeding, and support bonding [59,60]. After initial newborn stabilization, mothers and preterm infants can also derive the benefits of skin-to-skin contact in the birthing room [61].

The location of the newborn (above or below the level of the placenta) before cord clamping did not appear to significantly affect the volume of placenta-to-newborn transfusion in a randomized trial [62]. Therefore, concerns about transfusion volume should not influence the decision to place the newborn on the mother's abdomen.

In a meta-analysis (38 trials, 3472 participants), early skin-to-skin contact between mothers and their healthy newborns [59]:

●Increased the chances of exclusive breastmilk feeding in the first month after birth (83.5 versus 64.2 percent; risk ratio [RR] 1.30, 95% CI 1.12-1.49) and still feeding breastmilk at four months (RR 1.24, 95% CI 1.07-1.43)

●Increased the SCRIP (stability of the cardio‐respiratory system in preterms) score during the first six hours after birth, suggesting better transition to extrauterine life (standardized mean difference 1.24, 95% CI 0.76-1.72)

Breastfeeding — Early initiation of breastfeeding (within one hour of birth) and exclusive breastmilk feeding during the first month of life has substantial benefits in reducing neonatal mortality and morbidity. Several maternal benefits exist as well.

●(See "Initiation of breastfeeding".)

●(See "Infant benefits of breastfeeding".)

●(See "Maternal and economic benefits of breastfeeding".)

●(See "Breastfeeding: Parental education and support".)

POSTPARTUM ISSUES AND CARE — Postpartum issues and care are reviewed separately.

●Normal postpartum changes and routine care, including pain management and discharge planning (See "Overview of the postpartum period: Normal physiology and routine maternal care".)

●Postpartum contraception, including procedures for permanent contraception (See "Contraception: Postpartum counseling and methods" and "Postpartum permanent contraception: Procedures".)

●Postpartum problems and complications (See "Overview of the postpartum period: Disorders and complications".)

Routine administration of prophylactic antibiotics is unnecessary after an uncomplicated vaginal birth. Although a meta-analysis (three trials, 1779 participants) of this intervention for reducing maternal infectious morbidity found that it may reduce the risk of endometritis, it did not reduce the incidence of urinary tract infections, wound infection, or the length of maternal hospital stay [63]. Severe maternal infectious morbidity, antimicrobial resistance, and patient satisfaction with care were not evaluated, and the overall quality of evidence was low.

NEWBORN CARE — Routine newborn care may be provided by pediatric staff in the birthing room. If a pediatric provider does not attend the birth, the obstetric team may administer ophthalmic antibiotic agents, vitamin K, and the first dose of the hepatitis B vaccine to the infant. Routine newborn care is reviewed separately. (See "Overview of the routine management of the healthy newborn infant".)

Neonatal resuscitation is also reviewed separately. (See "Neonatal resuscitation in the delivery room".)

ALTERNATIVE BIRTHING PRACTICES THAT SHOULD BE AVOIDED — The American Academy of Pediatrics (AAP) advises avoiding the following alternative birthing practices because they have been associated with or may be associated with increased risks of neonatal morbidity and mortality (including infection) and have no clear medical or obstetrical benefits [64]. Supporting evidence linking each of these practices with increased risk is reviewed in the AAP guideline and elsewhere in this topic. We agree with avoiding these practices.

●Water birth (water immersion in early labor for maternal comfort is not harmful) (See "Labor and delivery: Management of the normal second stage", section on 'Water birth'.)

●Vaginal seeding (See "Cesarean birth: Postoperative care, complications, and long-term sequelae", section on 'Role of vaginal seeding'.)

●Nonseverance of the umbilical cord (See 'Umbilical nonseverance' above.)

●Placentophagy – Some patients are requesting their placentas for consumption postpartum (placentophagia or placentophagy) [65-67]. Various commercial enterprises are available to desiccate and encapsulate placental tissue, or it has been consumed raw or cooked. In one study, the most common reason for the practice was to prevent postpartum depression [68]. There is a lack of scientific evidence of any health benefits in humans, but potential harms have been documented [69,70].

●Nonmedical deferral of hepatitis B vaccination (See "Overview of the routine management of the healthy newborn infant", section on 'Hepatitis B vaccination'.)

●Deferral of ocular prophylaxis. However, the AAP has also taken the position that the need for legal mandates for ocular prophylaxis should be reexamined. They advocate for adoption of strategies to prevent ophthalmia neonatorum, such as compliance with recommendations for prenatal screening and treatment of Neisseria gonorrheae and Chlamydia trachomatis. Although ocular prophylaxis prevents ophthalmia neonatorum caused by Neisseria gonorrheae, it does not prevent the disorder from other common pathogens, such as Chlamydia species. In addition, increasing resistance to erythromycin among gonococci has been observed globally. Importantly, ophthalmia neonatorum can be treated effectively after it develops. In countries that have eliminated ocular prophylaxis, there have been no reported increases in cases of ophthalmia neonatorum or subsequent blindness. (See "Overview of the routine management of the healthy newborn infant", section on 'Eye care'.)

●Delayed bathing of newborns exposed to active herpes simplex virus (HSV) genital lesions or when there is a known history of bloodborne pathogens (HIV, hepatitis B or C virus)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Labor".)

SUMMARY AND RECOMMENDATIONS

●Definition – The third stage of labor is the time from fetal expulsion to delivery of the placenta. (See 'Introduction' above.)

●Cord clamping – Delaying cord clamping has newborn benefits in both term and preterm births.

•At term – For term infants who do not require resuscitation, we suggest delayed rather than immediate cord clamping (Grade 2C). The major benefit is on newborn hematological parameters. Not routinely delaying cord clamping is also reasonable as the improvement in iron stores needs to be balanced with the disadvantage of an increased risk for hyperbilirubinemia and more need for phototherapy. (See 'Term infants' above.)

•Preterm – For preterm births that do not require resuscitation, we recommend delayed rather than immediate cord clamping (Grade 1B). Providing more time for the physiologic transition from fetal to newborn life improves survival. (See 'Preterm infants' above.)

We delay cord clamping for at least 30 to 60 seconds as approximately 75 percent of blood available for placenta-to-fetus transfusion is transfused in the first minute after birth. The optimal duration is unclear.

In the stable mother, delaying cord clamping has no adverse maternal effects. (See 'Early versus delayed cord clamping' above.)

●Active management of placental separation and expulsion – Active management is a bundle of interventions including prophylactic administration of a uterotonic agent (usually oxytocin) any time after delivery of the anterior shoulder and controlled traction of the clamped cut cord until the placenta spontaneously separates and is expelled. Prophylactic uterine massage is sometimes performed but does not provide added benefit if a uterotonic drug is being administered. Active management reduces the risk of severe postpartum blood loss and blood transfusion compared with expectant (physiologic) management in randomized trials. The evidence supporting this approach is provided separately. (See "Management of the third stage of labor: Prophylactic pharmacotherapy to minimize hemorrhage", section on 'Active management'.)

●Length of the third stage – The time between birth of the infant and expulsion of the placenta is generally ≤30 minutes. Preterm births are associated with a longer third stage than term births. (See 'Length of the third stage' above.)

The placenta and fetal membranes should be examined to make sure they are intact. (See 'Active management' above.)

●Blood loss – Average blood loss at vaginal delivery is estimated to be <500 mL. Excessive bleeding (picture 1) may be related to atony, trauma, coagulopathy, placental abnormalities, or uterine inversion. (See 'Blood loss' above.)

●Repair of lacerations – The cervix, vagina, and perineum should be examined for evidence of birth injury. A routine rectal examination should also be considered because failure to recognize and repair an anorectal injury (mucosa and/or sphincter) can lead to serious long-term morbidity, most notably fecal incontinence. A repeat rectal examination is performed after perineal repair of any laceration that is more than superficial to identify inadvertently placed transmucosal sutures, which we would remove. (See 'Repair of lacerations' above.)

●Skin-to-skin contact and breastfeeding – In the absence of maternal or neonatal complications, skin-to-skin contact helps to stabilize neonatal physiological parameters, promote exclusive breastmilk feeding, and support bonding. (See 'Maternal-newborn interaction' above.)

●Alternative birthing practices – The following alternative birthing practices should be avoided because they have been (or may be) associated with increased risks of neonatal morbidity and mortality and have no clear benefits: water birth, vaginal seeding, umbilical cord nonseverance, placentophagy, nonmedical deferral of hepatitis B vaccination and ocular prophylaxis, and delayed bathing of newborns exposed to active genital herpes simplex virus (HSV) lesions or maternal history of bloodborne pathogens (eg, HIV, hepatitis B or C virus). (See 'Alternative birthing practices that should be avoided' above.)