How to Deliver the Placenta: Steps and Management

Delivering the placenta is the final stage of childbirth, and it typically happens within 5 to 30 minutes after the baby is born. The uterus continues contracting after delivery, and these contractions shear the placenta away from the uterine wall while constricting blood vessels to limit bleeding. In most hospital births today, providers actively assist this process with a combination of medication, gentle cord traction, and massage rather than simply waiting for it to happen on its own. How this stage is managed has a real impact on bleeding risk, and the choices involved are worth understanding.

What Happens Inside the Uterus After the Baby Is Born

Once the baby is out, the uterus does not stop working. It contracts at even higher intensity than during the pushing stage, compressing the area where the placenta was attached, cutting off blood flow, and causing the placenta to peel away from the uterine wall.¹ This process has two phases. First, there is a quiet period right after birth where the uterus “regroups” before contractions resume. Then the placenta begins detaching, usually starting at the center and working outward. As it separates, a small gush of blood and a slight lengthening of the umbilical cord signal to the provider that the placenta is ready to be delivered.

Skin-to-skin contact with the newborn plays a surprisingly direct role in this process. Placing the baby on the mother’s chest triggers a surge of endogenous oxytocin, the same hormone that drives uterine contractions. Research shows that immediate skin-to-skin contact increases uterine contraction right after birth, improves the completeness of the delivered placenta, and shortens the duration of this stage of labor.² So what looks like a simple bonding moment is also functional physiology.

Active Management Versus Waiting

There are two broad approaches to the third stage: active management, in which the provider intervenes with drugs and techniques to speed placental delivery, and expectant management, in which the provider lets the placenta come out on its own without routine intervention. A third approach, sometimes called physiologic care, goes beyond passive waiting by actively supporting the body’s own mechanisms through upright positioning, warmth, and immediate skin-to-skin contact, but still avoids drugs and cord traction.³

Active management is standard in most hospitals worldwide, and the evidence behind this preference is straightforward. A large randomized trial found that the rate of postpartum hemorrhage was roughly 7% with active management compared to about 17% with expectant management, more than doubling the risk when providers simply waited.⁴ A Cochrane review pooling multiple trials confirmed that active management reduces average blood loss, lowers the rate of bleeding over 500 mL, and reduces the need for therapeutic uterotonics and blood transfusions.⁵

Active management is not without trade-offs, though. The same Cochrane review found it may increase afterpains, nausea and vomiting, a rise in diastolic blood pressure, use of pain medication after birth, and a slightly higher chance of returning to the hospital for bleeding later on.⁵ It also probably lowers the baby’s birth weight slightly, because early cord clamping (part of the traditional active-management bundle) reduces the amount of blood that transfers from the placenta to the newborn. That particular downside has led many providers to update their practice, using the drug component of active management while still delaying cord clamping.

The Three Components of Active Management

Active management is a package deal with three parts, each targeting a different aspect of placental delivery and bleeding control. In practice, providers may use all three or pick and choose based on the clinical situation.

Uterotonic Drugs

The cornerstone is giving a uterotonic drug, usually oxytocin, right after the baby is born. Oxytocin stimulates the uterus to contract more forcefully, which both speeds placental separation and clamps down on blood vessels at the placental site. A Cochrane review found that prophylactic oxytocin, compared with no drug at all, reduces blood loss and the need for additional uterotonics.⁶ Older alternatives like ergot alkaloids (ergometrine) work too, but they carry more side effects, including nausea, vomiting, and high blood pressure, which is why oxytocin has become the default.

A more recent meta-analysis compared oxytocin alternatives, including carbetocin, misoprostol, and tranexamic acid, across both vaginal and cesarean births. For vaginal births, none of the alternatives showed a clear advantage over oxytocin in reducing blood loss or preventing hemorrhage. For cesarean births, the picture was different, with some alternatives showing measurable benefit.⁷ For a straightforward vaginal delivery, oxytocin remains the go-to drug in most settings.

Controlled Cord Traction

Once the provider sees signs that the placenta has separated, they apply gentle, steady downward traction on the umbilical cord with one hand while the other hand presses upward on the uterus through the abdomen (a technique called counter-traction) to prevent the uterus from being pulled inside out. The idea is to guide the already-detached placenta out, not to pull it free by force.

The evidence on controlled cord traction is interesting because it does less than you might expect for the most important outcome. A large multicenter trial found no difference in the rate of hemorrhage at or above 500 mL between women who received cord traction and those who did not. Where cord traction did shine was in reducing the need for manual removal of the placenta by about 30%, shortening the third stage, and lowering pain and anxiety reported by the mother.⁸ A Cochrane review of multiple trials echoed this, showing that the main benefit is preventing the scenario where the placenta gets stuck and has to be removed by hand.⁹

Cord rupture is a known risk, occurring in roughly 5% of cases in the large trial, and about half of those women ended up needing manual removal of the placenta.⁸ No cases of uterine inversion occurred in the trial’s cord-traction group, which addresses a common safety concern. The technique requires training to do properly, though, and Cochrane reviewers have noted that the limited benefits would not justify training birth attendants who do not already have this skill.¹⁰

Uterine Massage

The third component involves rubbing the top of the uterus (the fundus) through the abdomen to encourage ongoing contraction. This is often done both during and after placental delivery. In a small randomized trial, uterine massage after the placenta was delivered reduced mean blood loss and cut the need for additional uterotonics.¹¹ A comparative study also found that intermittent massage reduced blood loss during vaginal delivery, with a particularly notable benefit in women who already had risk factors for hemorrhage.¹²

The picture is more complicated when uterine massage is started before the placenta is delivered and combined with oxytocin. In that scenario, the Cochrane review found no added benefit for massage on top of oxytocin for preventing hemorrhage over 500 mL.¹¹ The practical takeaway is that massage seems most useful after the placenta is out, as a way to keep the uterus contracted and firm, rather than as a primary tool to speed separation.

The Role of Cord Clamping Timing

Cord clamping has become one of the most debated parts of third-stage management. Traditional active management called for clamping the cord almost immediately after birth, but a growing body of evidence on the benefits to the newborn, including higher iron stores and improved blood volume, led most professional organizations to recommend delaying clamping for at least 30 to 60 seconds, and sometimes longer. Some providers now practice what is called physiologic cord clamping, waiting until the cord stops pulsating entirely or even until after the placenta is delivered.

One study examining delayed clamping until placental delivery found that newborns showed a smoother transition in oxygen saturation and heart rate during the first five minutes of life compared to those whose cords were clamped early.¹³ This suggests that leaving the cord intact during the third stage allows the newborn to continue receiving oxygenated blood from the placenta while its own lungs and circulation are still getting started.

Midwives who practice physiologic third-stage care describe a nuanced approach where they avoid formal cord traction but may use a “gentle ease” to help the placenta out once it is clearly sitting in the vagina and has already separated. One researcher noted that midwives sometimes describe this as a “guilty secret” because it technically falls outside the strict definition of expectant management but is clearly different from the sustained, deliberate traction used in active management.¹⁴

When the Placenta Does Not Come Out

A retained placenta is diagnosed when the placenta has not delivered within a set time window after birth, though that window varies by institution from about 18 to 60 minutes. It can also be diagnosed sooner if significant bleeding begins before the placenta has been delivered.¹⁵ This happens for a few reasons. Sometimes the uterus is not contracting strongly enough to push the placenta out (a trapped placenta). Other times the placenta is abnormally attached to the uterine wall, ranging from a mild adhesion (placenta adherens) to a deeply embedded attachment (placenta accreta).

Risk factors for a retained placenta overlap heavily with risk factors for poor uterine contraction. These include prolonged oxytocin use during labor, high parity, preterm delivery, and prior uterine surgery.¹⁵ More recently identified risk factors include IVF conception, which carried nearly four times the odds of retained placenta in one study, as well as large-for-gestational-age babies, endometriosis, pre-eclampsia, and vacuum-assisted delivery.¹⁶ A history of a prior retained placenta is also a risk factor, and congenital uterine anomalies increase the likelihood as well.¹⁵

If the placenta does not deliver within about 30 minutes, the standard recommendation is manual removal under anesthesia, though the evidence behind that specific time cutoff is surprisingly thin.¹⁷ The provider inserts a hand into the uterus, identifies the cleavage plane between the placenta and the uterine wall, and manually peels the placenta away. It sounds dramatic, and it is — the procedure carries its own risks, including infection and heavy bleeding. Anesthesia options for manual removal include general anesthesia, spinal or epidural blocks, or intravenous sedation. A large retrospective study found that about 97% of manual removals in women without an existing epidural were done under general anesthesia, and that techniques avoiding tracheal intubation were associated with fewer complications, including lower rates of hypotension and blood transfusions.¹⁸

Uterine Inversion and Other Rare Emergencies

Uterine inversion, where the uterus turns inside out through the cervix, is one of the most feared complications of the third stage. It is rare, with reported incidence ranging from roughly 1 in 2,000 to 1 in 20,000 deliveries, but it is life-threatening when it happens.¹⁹ The classic scenario involves excessive cord traction applied before the placenta has separated, though it can also happen spontaneously. The mother experiences sudden severe hemorrhage, shock, and intense pelvic pain.

Treatment has to happen fast. The standard first-line approach is the Johnson maneuver, in which the provider pushes the inverted fundus back up through the cervix using the palm of the hand. Delaying this maneuver makes it harder to succeed, because the cervix begins contracting around the inverted tissue, forming a rigid ring. When that happens, drugs to relax the uterus may be given to loosen the ring enough to allow repositioning.²⁰ If manual replacement fails entirely, surgical correction becomes necessary.²¹

Inspecting the Placenta After Delivery

Once the placenta is out, the job is not quite done. The provider should perform a focused visual examination of the placenta, looking at the fetal surface (the shiny side with the cord and blood vessels) and the maternal surface (the bumpy, lobulated side that was attached to the uterus). The key question is whether it is complete. Missing fragments suggest that tissue remains inside the uterus, which can cause ongoing bleeding or infection. The membranes are also examined to check for completeness and any abnormalities. Current guidance recommends that every placenta receive this gross examination at delivery, and that any placenta with abnormal findings be sent for full pathological evaluation.²²

Ultrasound can help when the clinical picture is unclear. Color Doppler sonography has been used during the third stage to monitor placental separation in real time. In cases of normal separation, blood flow between the placenta and the uterine wall stops almost immediately after the baby is born. In cases of abnormal placental attachment, such as placenta accreta, blood flow from the uterine muscle into the placenta persists well beyond the normal period.²³ Improvements in ultrasound technology have made it possible to detect the onset of separation earlier, although the total duration of the third stage remains similar regardless of monitoring method.²⁴

What Happens to the Placenta Afterward

In most hospitals, the placenta is discarded as medical waste or sent to pathology. But a growing number of people have asked to take their placenta home, either for cultural or spiritual practices such as burial, or for consumption. Placentophagy, the practice of eating one’s own placenta, has gained popularity in recent years. Advocates claim it boosts breast milk supply, improves mood, and reduces postpartum depression.

The scientific evidence for these claims is essentially nonexistent. A comprehensive review found no clinical benefit of human placentophagy and noted that the hormones and nutrients present in raw placental tissue are substantially degraded by the steaming and dehydration process used to make placenta capsules.²⁵ Laboratory analysis confirmed that all measured hormones, including oxytocin, were significantly reduced by processing.²⁶ More concerning, the CDC has issued a warning about the practice after a newborn developed recurrent bacterial sepsis linked to contaminated placenta capsules the mother was taking. The encapsulation process does not reliably eliminate infectious pathogens.²⁵ While the concentrations of potentially toxic metals like arsenic and lead in raw placental tissue appear to fall below toxicity thresholds, the infection risk remains a genuine concern.²⁶

1
American Journal of Obstetrics and Gynecology. Third stage of labor: evidence-based practice for prevention of adverse maternal and neonatal outcomes
2
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PubMed Central. A Comparison of Physiologic Third‐Stage Care, Expectant Management, and Oxytocin Prophylaxis in the Prevention of Postpartum Hemorrhage Following Physiologic Labor and Birth: A Systematic Review
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PubMed Central. Comparing oxytocin alternatives for postpartum hemorrhage prevention in vaginal and caesarean births: a systematic review and meta-analysis
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PubMed Central. Effectiveness of Intermittent Uterine Massage in Reducing Blood Loss During Vaginal Delivery: A Comparative Study
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PubMed. Is Delaying Cord Clamping until Placenta Delivery Beneficial? Oxygen Saturation and Heart Rate Transition during the Initial 5 Minutes after Delivery in Indian Healthy Newborns
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PubMed Central. Retained placenta after vaginal delivery: risk factors and management
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PubMed Central. Novel risk factors associated with retained placenta after vaginal birth
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PubMed Central. Successful Management of Acute Puerperal Uterine Inversion After Vaginal Delivery: A Case Report of a 43-Year-Old Multiparous Woman
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PubMed Central. Acute Puerperal Uterine Inversion Following a Vaginal Delivery: A Case Report
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PubMed. Human placentophagy: Effects of dehydration and steaming on hormones, metals and bacteria in placental tissue