How Is the Placenta Removed After a Normal Delivery?

After a vaginal birth, the placenta typically delivers itself within about five to thirty minutes through a combination of continued uterine contractions and, often, gentle assistance from a midwife or doctor. This final phase of childbirth is formally called the third stage of labor, and while it rarely gets much attention compared to pushing a baby out, how it is managed has real consequences for bleeding risk and recovery. The process can be hands-off or hands-on depending on clinical circumstances and your preferences, and the evidence behind each approach is worth understanding.

What Happens Naturally After the Baby Is Born

Once the baby is delivered, the uterus continues contracting. These contractions serve a different purpose now: they shear the placenta away from the uterine wall. The placenta was anchored to the uterus through a specialized layer of tissue, and as the uterus shrinks rapidly after birth, the attachment site becomes much smaller than the placenta itself. That mismatch in surface area causes the placenta to buckle and peel off, much like a sticker lifting from a deflating balloon. A drop in progesterone also plays a role, triggering changes in blood flow through the maternal blood vessels at the attachment site that help limit bleeding as the placenta separates.

You may feel a brief return of cramping or pressure, and sometimes a gush of blood signals that the placenta has detached. Your care provider watches for signs of separation: a small gush of blood from the vagina, the umbilical cord appearing to lengthen as the placenta drops lower, and the uterus rising and becoming firmer and more globe-shaped. Once these signs appear, a gentle push from you or light guidance from the provider is usually all it takes for the placenta to slide out.

Active Management Versus Expectant Management

There are two broad strategies for handling this stage. In expectant (or physiological) management, the provider waits for the placenta to separate and deliver on its own, intervening only if there is a problem. In active management, the provider takes several steps to speed things along and reduce the risk of heavy bleeding. Active management usually includes giving a uterotonic drug (most commonly oxytocin), clamping and cutting the cord, and applying controlled cord traction to help guide the placenta out once it has separated.

Active management is recommended as the standard approach by most obstetric guidelines worldwide because it lowers the chance of postpartum hemorrhage. A Cochrane systematic review found that active management reduces average blood loss and likely reduces the rate of blood loss over 500 mL, as well as the need for therapeutic uterotonics and blood transfusion.¹ A separate clinical guideline similarly concluded that active management reduces postpartum hemorrhage risk and should be offered to all women.²

Active management is not without trade-offs. The same Cochrane review noted that it may increase afterpains, nausea and vomiting after birth, the use of pain medication in the immediate postpartum period, and a slightly higher rate of women returning to the hospital with bleeding later on.¹ It also tends to reduce the baby’s birth weight slightly, because early cord clamping interferes with the transfer of blood from the placenta to the newborn. For low-risk births where a woman strongly prefers a physiological approach, expectant management remains a reasonable choice, but the conversation about bleeding risk should happen beforehand.

The Role of Oxytocin

Oxytocin is the most commonly used uterotonic during the third stage. It stimulates the uterus to contract more forcefully, which both speeds placental separation and clamps down on the open blood vessels at the attachment site. It can be given as an injection into the thigh or upper arm (intramuscular) or directly into a vein (intravenous). The reduction in postpartum hemorrhage risk is primarily attributed to this drug.³

Whether oxytocin is given before or after the placenta comes out does not seem to make a major difference in outcomes. A randomized trial comparing the two timings found no change in bleeding rates or in how long the third stage lasted, and giving oxytocin early did not raise the risk of the placenta getting trapped inside.⁴ The route of administration does matter, though. A meta-analysis found that intravenous oxytocin outperformed intramuscular oxytocin on several measures: women who received the intramuscular injection had higher rates of severe hemorrhage, were more likely to need a blood transfusion, and were more likely to need manual removal of the placenta.⁵ In practice, intramuscular injection remains common because it is simpler and does not require IV access, but when an IV line is already in place, the intravenous route appears to be the better option.

Controlled Cord Traction

Controlled cord traction is the gentle, steady pulling on the umbilical cord while the other hand presses against the lower abdomen to stabilize the uterus. It sounds simple, but the technique requires training. The provider never yanks the cord; they apply traction only after confirming signs that the placenta has separated. Pulling on a still-attached placenta risks a serious complication called uterine inversion, where the uterus essentially turns inside out.⁶

The evidence on whether cord traction actually reduces heavy bleeding is mixed. A large multicenter trial found no difference in the rate of postpartum hemorrhage between women who received controlled cord traction and those who were allowed to push the placenta out on their own. However, cord traction did cut the need for manual removal roughly in half and shortened the third stage considerably: only about 4.5% of women in the traction group had a third stage longer than 15 minutes, versus about 14% in the group without traction. Women in the traction group also reported less pain and discomfort.⁷ A Cochrane review pooling multiple trials similarly found that cord traction reduced the chance of needing manual removal and shortened the third stage, though it did not clearly prevent severe hemorrhage.⁸

A WHO trial compared a “full package” of active management (uterotonic plus cord traction) against a simplified package that dropped the traction. The simplified approach led to slightly more bleeding, a longer third stage, and a higher rate of manual placenta removal.⁹ So while cord traction alone is not a strong weapon against hemorrhage, it does appear to make the process faster and less likely to require manual intervention.

When the Cord Gets Clamped

Cord clamping used to happen almost immediately after birth as part of active management. That practice has shifted. Delayed cord clamping, typically waiting at least 30 to 60 seconds and often longer, allows blood to continue flowing from the placenta into the baby. This gives the newborn higher hemoglobin levels, better iron stores, and improved outcomes on a range of measures.¹⁰

The amount of blood transferred from the placenta to the baby is not simply a function of how long you wait. Factors like whether the baby has started breathing, whether the baby is crying, and whether the uterus is contracting all influence which direction blood flows through the cord vessels.¹¹ In most guidelines today, delayed clamping is considered compatible with active management. The oxytocin injection can be given while waiting to clamp, and cord traction is applied after the cord is eventually cut.

What Happens If the Placenta Does Not Come Out

A retained placenta is diagnosed when it has not delivered within a set time after birth. That cutoff varies by institution, ranging from 18 to 60 minutes, but 30 minutes is the most commonly cited threshold.¹² It can also be diagnosed earlier if significant bleeding begins before the placenta is out.

There are three main reasons a placenta stays behind. The first is that the uterine muscle behind the placenta fails to contract properly, leaving the placenta loosely attached but not sheared off. The second is that the placenta has separated but gets trapped behind a cervix that has started to close. The third, and most medically significant, is that a small area of the placenta has grown abnormally deep into the uterine wall, a condition on the spectrum of placenta accreta.¹³ Risk factors for retained placenta include prior retained placenta, previous uterine surgery, and preterm delivery.

Before resorting to manual removal, providers sometimes try less invasive approaches. One technique is injecting oxytocin solution through the umbilical vein, which delivers the drug directly to the placental bed. A Cochrane review found that oxytocin injected into the umbilical vein in saline reduced the need for manual removal compared to saline alone.¹⁴

Manual Removal

If the placenta remains stuck despite uterotonic medications and other measures, the provider may need to remove it by hand. Manual removal is done under anesthesia, either regional (spinal or epidural) or general. The provider reaches inside the uterus and carefully peels the placenta away from the uterine wall using the edge of the hand, then brings it out. The procedure is common enough that it is a core obstetric skill, yet the evidence base for exactly when to intervene is surprisingly thin. The 30-minute rule is a widely followed convention rather than a firmly evidence-backed cutoff.¹⁵

For most women, manual removal goes smoothly and resolves the situation. But it is not a minor event psychologically. A qualitative study of women who underwent the procedure found that fear, anxiety, and significant pain were common experiences, even with analgesia. Women who went through repeated attempts described the experience as an ordeal, and many expressed a desire for more information and emotional support from their care team before and during the procedure.¹⁶ If you have a birth plan, it is worth knowing that this procedure exists and asking your provider in advance about what circumstances would trigger it.

When the Placenta Has Grown Too Deep

In rare cases, the placenta invades beyond its normal boundary and grows into the muscle of the uterus. This is called placenta accreta spectrum, and it ranges from superficial invasion into the muscle layer to full penetration through the uterine wall and into surrounding organs.¹⁷ When this happens, the placenta cannot separate normally, and attempted manual removal can cause life-threatening bleeding. These cases are typically identified on imaging before delivery and managed with a surgical team standing by, often ending in a cesarean delivery with possible hysterectomy. Accreta spectrum after a vaginal birth is uncommon but does occur, particularly as small focal areas of abnormally deep attachment that are only recognized when the placenta will not come away cleanly.

Checking the Placenta After Delivery

Once the placenta is out, your provider will examine it carefully. This is not a formality. The placenta has a maternal side (rough and divided into lobes called cotyledons) and a fetal side (smooth, covered by membranes, with the umbilical cord attached). The provider checks that all the cotyledons are present and intact, that the membranes are reasonably complete, and that the cord has the expected number of blood vessels. Missing fragments can mean tissue has been left behind in the uterus, which raises the risk of bleeding and infection. An extra lobe of placental tissue, sometimes located some distance from the main placenta and connected to it by blood vessels running through the membranes, can be missed if the membranes tear during delivery. Thorough inspection after delivery is the primary way to catch this.¹⁸

Uterine Massage and Monitoring After the Placenta Is Out

Even after the placenta delivers completely, the work is not finished. The uterus needs to stay firmly contracted to compress the blood vessels at the former placental site. Nurses or midwives will palpate your abdomen regularly over the next several hours to check that the uterus feels firm and is shrinking. If it feels soft or “boggy,” that is a warning sign of uterine atony, the leading cause of postpartum hemorrhage.

Uterine massage, where the provider firmly rubs the top of the uterus through the abdomen, is a standard response to a soft uterus. Some providers also perform it routinely after the placenta is delivered as a preventive step. One study found that massage was associated with reduced blood loss and lower need for additional uterotonic drugs in the first two hours after delivery.¹⁹ A Cochrane review, however, found the evidence for routine uterine massage inconclusive and called for more research before changing practice guidelines.²⁰ In practice, most providers will massage a soft uterus without hesitation; the debate is more about whether massage should be routine for every woman or reserved for those who need it.

What Does the Third Stage Feel Like

Many women barely notice the placenta coming out, especially if they are holding their newborn for the first time. In a qualitative study of women’s experiences, a recurring theme was that attention was firmly on the baby, and the placenta felt like an afterthought.²¹ Some women described a sensation of pressure or mild cramping, and a few found it uncomfortable, but it is rarely described as painful on the scale of the labor that preceded it.

Afterpains, the cramping that continues as the uterus contracts down over the following hours and days, are a different story. These can be genuinely painful, especially for women who have given birth before. One study comparing active and expectant management found that afterpains were more intense the day after birth than in the immediate hours afterward, and that women who had previously given birth reported significantly more pain than first-time mothers regardless of which management approach was used.²² This is worth knowing because afterpains can catch you off guard. Breastfeeding triggers oxytocin release, which stimulates contractions, so nursing sessions in the first days can bring on a wave of cramping. Over-the-counter pain relief and warm compresses are usually sufficient.

Lotus Birth and Other Alternative Practices

In a lotus birth, the umbilical cord is never cut. The placenta stays attached to the baby and is carried around, usually wrapped in cloth or placed in a special bag, until the cord dries out and detaches naturally over the course of several days. Advocates describe it as a gentler transition for the newborn. The medical concern is straightforward: a detached, devitalized organ sitting at body temperature is an invitation for bacterial growth. Case reports have documented neonatal omphalitis (infection of the umbilical stump) following lotus birth.²³ A case series from a Tanzanian hospital similarly noted that the risk of neonatal infection increases with this practice, and that families who choose it need clear guidance on postpartum hygiene.²⁴ No professional obstetric organization endorses lotus birth, and it is distinct from delayed cord clamping, which involves a wait of seconds to minutes, not days.

What Happens to the Placenta Afterward

In most hospitals, the placenta is treated as medical waste and incinerated after a pathology review if one is indicated. But this default varies widely around the world and even within countries. In many cultures, the placenta carries deep symbolic meaning. Burying it is among the most widespread traditions globally: under a tree, at the family home, or at a specific ritual site. A survey of perinatal pathologists found that the most common reason parents requested their placenta was to bury it, though some requested it for consumption or encapsulation.²⁵ Among Australian home-birthing women, researchers found that the placenta was constructed as a meaningful element of the birth experience rather than clinical waste, with rituals ranging from burial ceremonies to art-making.²⁶

Whether you can take your placenta home depends on local hospital policy and regional regulation. In South Africa, for example, indigenous women giving birth at healthcare facilities are given the option of taking the placenta home for indigenous disposal, though precise guidelines for how this should happen safely are still lacking.²⁷ In many US and UK hospitals, requesting your placenta is allowed but requires advance notice and a signed release form. If this matters to you, raise it with your birth team well before your due date so the logistics can be worked out.