which may lead to the placenta only partially separating from the uterine wall (Johnson and Taylor 2006), which may in turn be a cause of excessive bleeding and postpartum haemorrhage. Spencer (1962) suggested controlled cord traction (CCT) should be com- menced as soon as the uterus contracts and this was a traditional aspect of an actively managed third stage. However, since then Levy and Moore (1985) have suggested that it is preferable to wait for further signs that placental separation has occurred.
Signs of separation include the rising of the fundus and the hard- ening of the uterus as described above, coupled with a gush of blood from the vagina and a lengthening of the umbilical cord. Levy and Moore (1985) found no signifi cant difference in the incidence of postpartum haemorrhage (PPH) or the length of the third stage between those who commenced CCT immediately they felt the uterus contract and those who waited for signs of separation.
However, the incidence of PPH did increase signifi cantly when the midwife unsuccessfully applied CCT without waiting for signs of placental separation.
CCT involves the midwife either wrapping the cord around her fi ngers or using a clamp to apply downward, sustained pressure until the placenta becomes visible at the vulva. Once the placenta can be seen, the traction is applied upwards to follow the curve of the vagina. The placenta is then delivered into a bowl. Care should be taken of any trailing membranes and the midwife may need to use forceps to gently tease the membranes out of the vagina. Alter- natively, twisting the trailing membranes into a rope may be useful and some midwives ask the woman to cough gently to assist this process.
Some midwives place their hand above the symphysis pubis while undertaking CCT and push the uterus upwards. This is known as
‘guarding the uterus’ and is thought to prevent the uterus being pulled inside out (uterine inversion). However, there is no evidence to suggest that this is necessary (Harris 2004).
whether suturing of the area is needed. This is often an uncomfort- able examination and the midwife should make sure that the woman has Entonox to use if required and that she understands why she is being examined. All effort should be made to reassure and relax her.
It may be helpful if the partner holds her baby close to her as a way of distracting her from the examination.
Conclusion
This chapter has focused on the physiological aspects of labour with an emphasis on the role of the midwife in promoting normality. For issues relating to care of women in high-risk situations the reader is referred to the obstetric literature. Emergency scenarios are dis- cussed in Chapter 6. The role of the midwife in empowering the woman to cope with the tremendous physical and emotional demands of childbirth has also been highlighted. It is acknowledged that labour is a complex, multifaceted process with physical, psy- chosocial and emotional elements underpinning it. As the Midwives Rules and Standards (NMC 2004) emphasise, childbirth is much more than simply the act of giving birth. It is a continuous process from conception, through pregnancy, labour, birth and beyond. Many factors unique to the individual woman will impact on the process and it is essential that midwives are competent to provide effective and appropriate care during this time. The midwife will need to use her skills to support the individual needs of each woman she cares for in whatever setting she is working (for example, the home, the hospital or birth centre) and regardless of the woman’s cultural background and individual preferences.
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