Optimising psychophysiology in third stage of labour: Theory applied to practice

Article Outline

• Summary
• Introduction
  • Literature review
  • Psychophysiology in third stage of labour
  • Midwifery Guardianship for a natural third stage of labour
• Midwifery Guardianship to optimise normal physiology
• Skills for supporting natural placental birth
• Conclusion
• References
• Copyright

Summary 

Background

Active management of the third stage of labour is routine in delivery suites. New South Wales (NSW) Health has a policy which prescribes active management because medically designed randomised controlled trials have claimed a reduced blood loss in third stage with active, compared with ‘physiological’, management. In home and birth centre settings however, physiological third stage is common as women who access these settings prefer to labour without medical intervention and midwives who work in these settings adopt a holistic approach to working with women. The holistic approach is psychophysiological as the midwife engages with and supports integration of the woman's spirit, mind and body in her childbearing process.

Purpose

To present midwifery theory that describes, explains and predicts how women and midwives work together to enable selected women to safely experience an optimal psychophysiological third stage of labour.

Method

Key terms are defined. The literature relevant to psychophysiology and management of the third stage of labour is reviewed. An expanded understanding of risk factors for postpartum haemorrhage is presented and justified. A theoretical framework of Midwifery Guardianship is presented and discussed and applied to third stage care.

Conclusions

A psychophysiological third stage is quite different from what has been defined as ‘physiological management’ in the medically designed randomised trials comparing active versus physiological care. The conditions for deciding if a particular woman, in a particular context with a particular midwife is a good candidate for a psychophysiological third stage are presented and discussed. Only if all these conditions are met it is safe to proceed with a psychophysiological third stage. Research about the effectiveness of midwifery care in a psychophysiological third stage of labour urgently needs to be conducted.

Keywords: Psychophysiology, Expectant management third stage of labour, Physiological third stage of labour, Midwifery Guardianship, Postpartum haemorrhage, Risk factors

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Introduction 

The focus of this paper is on women who choose to give birth within a model of midwife-led care. For the sake of simplicity, the term ‘birth centre’ will be used to encompass both home and birth centre settings in this discussion. Another assumption for the purpose of this paper is that women who give birth in birth centres are considered to be medically low risk for birth-related complications as indicated by the Australian College of Midwives Guidelines for Consultation and Referral.¹ Women who make the choice to give birth in a birth centre do so because they want to give birth naturally, in their own way at their own time; this includes the way they want to experience the third stage of labour. The third stage of labour is defined as that time extending from the birth of the baby until the birth of the placenta.² How the woman experiences the third stage of labour differs on whether the third stage is being medically managed or whether the midwife and woman are working together for a psychophysiological birth of the placenta.

Medically-led care of childbearing women includes the use of active management of the third stage of labour. As delivery suites are generally medically-led, medical management of the third stage is the usual practice in these environments.³, ⁴, ⁵ The Joint Statement by the International Confederation of Midwives (ICM) and the International Federation of Gynaecologists and Obstetricians (FIGO) on the management of the third stage of labour to prevent post-partum haemorrhage (2006) highlighted three essential components of active management. These components are: administration of uterotonic agents, controlled cord traction and uterine massage of the uterus after delivery of the placenta, as appropriate (p. 1100).⁵

An article by authors associated with the Safe Motherhood project⁴⁸ provides clear, step-by-step instructions for the active management of the third stage of labour in line with the ICM/FIGO statement.⁵ The steps are summarised in Table 1.

Table 1. Steps in active management of third stage⁴⁸.

Within 1min of the birth of the baby, palpate the abdomen to rule out the presence of an additional baby(s) and give oxytocin 10units IM. Some authorities suggest giving the oxytocic with the anterior shoulder of the baby

Clamp the cord close to the perineum (once pulsation stops in a healthy newborn)

Keep slight tension on the cord and await a strong uterine contraction (2–3min)

With the strong uterine contraction, encourage the mother to push and very gently pull downward on the cord to deliver the placenta while maintaining counter traction above the pubic bone

As the placenta delivers, hold the placenta in both hands and gently turn it until the membranes are twisted. Slowly pull to complete the delivery

Immediately after the placenta is born, massage the fundus of the uterus until the uterus is contracted

There is much debate and uncertainty about what constitutes physiological third stage. Fry⁶ interviewed community midwives to determine what they consider to be midwifery care for a physiologically normal third stage of labour. Fry's steps for physiological third stage are summarised in Table 2.

Table 2. Fry's steps for physiological management of third stage⁶.

We accept all of these characteristics of physiological third stage but we go further. We present a theory, Midwifery Guardianship,⁷ described in some detail below, aimed at describing, explaining and predicting how to optimise the interaction between consciousness, psychology and physiology and enable women to safely experience a psychophysiological third stage of labour.

In this paper we review the background research concerning medical versus midwifery led care in the third stage of labour. Next the psychophysiology of birth is explored by considering animal research, including human research where that is available. The theory of Midwifery Guardianship is presented and we describe how a midwife can best work with a woman to safely experience an optimal psychophysiological third stage of labour in a birth centre. The field of psychophysiology incorporates the domains of psychology, physiology, immunology, genetics, endocrinology, neuroscience, biology, quantum physics and many other scientific arenas which seek to understand the confluence of spirit, mind and body in human health and disease.⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷

Literature review 

The Cochrane Review of active management versus expectant management of the third stage of labour¹⁸ has been cited by the NSW Department of Health³ and the ICM FIGO Statement on Third Stage Care⁵ as the basis for the strong recommendation that all women should have the birth of their placentas actively managed. That Cochrane Review was based on four randomised controlled trials of the effectiveness of third stage of labour care.¹⁹, ²⁰, ²¹, ²² In summary, the existing research finds that, at least in a hospital setting, active management is more effective than expectant management in reducing postpartum haemorrhage (PPH) rates. There are a number of reasons why this research should not be generalised to birth centre settings. First, the Cochrane Review (p. 2)¹⁸ defined ‘expectant management’ in a very limited way:

This definition leaves out many elements of physiological third stage that midwives believe are important.⁶ Second, women who were part of the randomised controlled trials all had standard hospital antenatal and intrapartum care and are for that reason, a different population of women compared with women who choose birth centres. Third, the study sample included women who were at known medical risk of PPH (see Table 1). Finally, the Cochrane reviewers themselves acknowledge that their findings cannot be generalised to home and birth centre settings.¹⁸ Therefore, there is no compelling evidence to support the active management of the third stage of labour in birth centre settings.

Psychophysiology in third stage of labour 

Reproductive physiology is the same in all mammals; the key difference is that human mammals have higher brain activities such as consciously being able to think about the past, the present and the future and the ability to decide on a particular course of action.¹³, ¹⁴ The ability to think and choose has psychophysiological effects.⁸, ¹³, ²⁷, ²⁸, ²⁹, ³⁰, ³¹ The current understanding about psychophysiology and how it can be related to third stage labour and birth of the placenta is summarised below. One way in which psychophysiology operates is at the foundational level of genetic expression and regulation. Genetic blueprints are the basis for all normal, physiological processes.⁸, ¹³, ¹⁴, ¹⁶, ²⁴ Genetic blueprints express themselves optimally in appropriate internal and external environmental conditions. If internal and/or external environmental factors are inappropriate to the situation then normal regulatory gene function may be disrupted which interferes with normal physiology and places the individual at risk of disease.⁸, ¹⁶ In the case of the third stage of labour this means that the expression of oxytocin creating genes may be disrupted. Human consciousness is an intrinsic factor which influences genetic expression and physiological processes and behaviour.⁸, ¹³, ¹⁴, ¹⁵, ¹⁶, ¹⁷, ³¹ Human consciousness includes the person's intention, attention and focus involving varying combinations of brain structures and chemical messengers such as neurotransmitters, hormones and cytokines.⁸, ¹³, ¹⁴, ²⁵ Our focus with Midwifery Guardianship is to support the woman to express the optimal genetic blueprint for birthing the placenta.

Another way in which the third stage of labour can be affected by psychophysiology is the impact that birthing environment has on the autonomic nervous system and hormonal regulation. The impact of the birthing environment has been investigated by scientists using a variety of mammalian species.²⁶ During unhindered natural labour and birth, reproductive hormones are released in an exquisite cascade that optimises birth physiology and healthy psychological functioning for mother and baby.⁸, ²⁷, ²⁸, ²⁹, ³⁰ The hormones include oxytocin, endorphins, prolactin, adrenocorticotrophic hormone (ACTH) and catecholamines.⁸, ⁹, ¹⁰, ¹¹, ¹² Oxytocin is the major hormone involved in uterine contractability, bonding, caretaking, breastfeeding and all loving sexual activity.⁸, ⁹, ¹⁰, ¹¹, ¹² During the third stage of labour, the mother's levels of oxytocin increase in response to the smell and touch of her baby; most particularly during breastfeeding.⁹, ³⁰ During a physiological third stage of labour, oxytocin floods the woman's brain, triggering feelings of profound love for her infant.⁸, ¹², ²⁷, ²⁸, ²⁹ High levels of oxytocin spill over into the mother's blood circulation.¹⁰ This hormonal response is exactly what the woman needs so that strong uterine contractions continue during third stage, enabling the placenta to be born naturally with sustained haemostasis.⁹

In comparison, if a woman is given an injection of artificial oxytocin, it disrupts the release of her own natural oxytocin.⁹ The artificial oxytocin is unable to cross the blood–brain barrier and therefore the woman may miss out on the big rush of brain-based oxytocin and its behavioural effects.⁹ In animal studies, if oxytocin is blocked from acting in the maternal brain then young animals are most usually rejected.³⁰ On a biological and behavioural level, actively managing the third stage of labour may have implications for women and their babies because the physiologically induced behavioural effects can be subtle and yet have long lasting repercussions in attachment processes.³¹

For all mammals, including humans, the autonomic nervous system (ANS) is constantly modulating the internal environment. It does this through the interaction of its branches, the parasympathetic (PNS) and sympathetic nervous system (SNS) in an allostatic response to intrinsic or extrinsic environmental cues.⁸ Both the PNS and the SNS can “vary reciprocally, coactively or independently” (p. 438).⁸ When the social and physical environment is calm and safe, basic bodily processes, e.g. eating, digesting, sleeping, making love, eliminating, labouring, birthing and breastfeeding are functioning under PNS control.⁸, ²⁷, ²⁸, ²⁹, ³⁰ If, during the third stage of labour, the mother feels the need to be attentive to external matters, or even worse, if she actually feels fearful, her SNS becomes dominant in the fight, flight or freeze³², ³³ response. Activation of the stress response inhibits reproductive function and behaviour.⁸ When the SNS is dominant, the whole body is flooded with catecholamines which repress the activity of oxytocin neurons.⁸, ¹¹, ¹², ²⁷, ²⁸, ³² The acute stress response results in inhibition of processes which are not essential to immediate survival, such as gastrointestinal secretion, uterine and motor activity. Likewise, when women are overwhelmed with joy and excitement, high levels of enkephalins and beta-endorphins inhibit the release of endogenous oxytocin.¹⁰ This process, paradoxically, acts on receptors in the uterus in ways that can cause the uterus to relax instead of contract during third stage.¹⁰, ¹¹ Over-excitement can therefore also lead to uterine atony which is the major cause of PPH.³, ³⁴, ³⁵, ³⁶

What happens during birth may also affect what women think and feel. For instance, early skin-to-skin contact between the mother and her baby has been shown to improve maternal attachment behaviour and maternal affectional love/touch scores during breastfeeding.³⁷, ³⁸ For the mother, skin-to-skin contact with her baby at birth triggers the highest levels of the love and attachment hormone, oxytocin, promoting attachment with her baby and triggering uterine activity which releases the placenta and controls bleeding.¹⁰

Midwifery Guardianship for a natural third stage of labour 

‘Midwifery Guardianship’ is part of the broader theory ‘Birth Territory and Midwifery Guardianship’.³⁹ It is not possible to describe and explain the whole of Birth Territory and Midwifery Guardianship theory in a few paragraphs so only key concepts are presented here. The reader is referred to the book for a much more complete discussion of the theory.³⁹ Midwifery Guardianship is a holistic concept.⁴⁰

Based on contemporary scientific understandings, Midwifery Guardianship is premised on the assumption that what women and midwives think, feel and imagine has actual physiological effects.⁸, ¹³, ¹⁴, ¹⁶, ²³, ³⁷ Midwifery Guardianship aims to optimise the woman's reproductive psychophysiology. The midwifery guardian's focus is on nurturing the woman's sense of confidence and safety through a trusting relationship within which the woman's attitudes, values and beliefs are respected and of primary importance. Midwifery Guardianship involves guarding the woman and her Birth Territory so that she may labour, feeling safe and supported, without unwanted intrusions, distractions or interruptions.⁷, ³⁹

The ability to practise as a Midwifery Guardian in the third stage of labour assumes that the woman and the midwife are in a ‘sanctum’ for birth.⁷ Briefly, a sanctum is a homelike, private, warm, dimly lit environment that feels physically and emotionally safe for the woman. Feeling safe usually involves the woman knowing the midwife as the basis for trusting her.⁷ A Midwifery Guardian works with the woman so that she is able to slow down her everyday thinking mind and focus mindfully on her baby, her body and the birthing process.⁷ The Midwifery Guardian promotes and respects the woman's own, internal power to birth. We call this power ‘integrative’ because when the woman is using her internal power she will be integrating her thoughts, feelings, actions and imaginings with her bodily sensations. Using her inner power in a focussed, mindful way engages complex neuronal networks, creating altered states of consciousness that allow optimal birthing physiology to proceed unimpeded.⁷, ⁸, ¹⁰, ¹⁵, ²⁷, ²⁸, ²⁹, ³⁰ A woman who is using ‘integrative power’ will feel strong and able. By comparison, a woman who feels weak and powerless is using ‘disintegrative power’ where her thoughts and feelings are undermining her body's physiological capacity.⁷ Supporting women to find and use their own integrative power is a different activity from the obstetric concept that the woman needs to be ‘rescued’ from suffering and ‘delivered’ of her baby.

The aim of ‘Midwifery Guardianship’ is to integrate all forms of power within the birth environment towards a shared higher goal, in this case, ‘genius birth’. A genius birth is a somewhat different concept than a ‘normal birth’. A ‘genius birth’ is defined as one where the woman uses her own power to give birth in the best possible, uniquely individual way, for that particular woman at that particular moment of her life.⁴¹ A genius birth may or may not involve interventions. What is critical to a genius birth is that the woman is the ultimate decision-maker and that she feels empowered no matter what interventions may occur.⁴¹ A ‘forced birth’, by comparison, is one that is primarily devoid of spontaneity and is contrived to fit the pre-determined expectations of the woman and/or her attendants.⁷, ⁴¹ In our view, a forced birth is disintegrative of women's inner power and can lead to uterine inertia. In Guardianship, midwives do not ‘manage’ third stage at all; instead we work with the woman to enable her to use her own inner power to simultaneously birth her placenta, love her baby and achieve sustained haemostasis. In contrast, active management of third stage uses power external to the woman to deliver the placenta and achieve haemostasis. We believe that unless the woman is fully involved in deciding what happens to her, then the use of external power can be disintegrative of her own inner power with unintended consequences, such as PPH.

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Midwifery Guardianship to optimise normal physiology 

Guarding the woman and baby during a natural third stage of labour promotes sensory experience between them and allows the heightened awareness and emotionality that strengthens the loving bonds that are being created. Sensory experience during mother and baby skin-to-skin contact includes the mother and baby's pheromones, the body-to-body movement, pressure, softness and warmth from the baby and mother's skin touching, together with visual and auditory cues.³¹ For the baby, sensory awareness includes the experience of the mother's heartbeat, which instantly causes the baby's level of cortisol to plummet, leading to calmness and optimal somatosensory neural network formation for the baby.³¹ The birth environment needs to be one where the mother and infant feel safe, only then can they focus on the experience of attaching to each other. It is our view that a natural labour, including the third stage, is more achievable where there is continuity of care from a known midwife and the environment is either home or birth centre (see Table 3).

Table 3. Medically accepted risk factors for postpartum haemorrhage², ³.

Factors that should be identified prior to the start of labour
Previous history of primary PPH	e.g. associated with uterine atony, not trauma
Abnormal uterine anatomy	e.g. fibroids, uterine septum, previous uterine surgery including caesarean
Over distended uterus	e.g. due to multiple gestation, macrosomia or polyhydramnios, parity of six or greater
Abnormalities of the placenta	e.g. low lying placenta, placenta accreta, percreta, placenta praevia
Antepartum haemorrhage	e.g. associated with the placenta
Hb of less than 110g per litre
Abnormalities of coagulation	e.g. due to: fetal death in utero, hypertension, clotting diseases, anti-coagulant therapy, ante-partum haemorrhage, general infections
Factors identified prior to, or within a minute of, the baby's birth
Obstetric or anaesthetic interventions	e.g. induction, augmentation, epidurals, forceps, vacuum, shoulder dystocia, episiotomy or tear requiring suturing
Intrapartum haemorrhage
Uterine muscle exhaustion	e.g. due for example to induction, augmentation or labour longer than 15h or maternal exhaustion
Intra-amniotic infection	indicted by: pyrexia and/or prolonged ruptured membranes (<24h)
Drug induced uterine hypotonia	e.g. magnesium sulphate, nifedipine and salbutamol. This list of risk factors is primarily derived from the New South Wales Health Policy Directive1 but also adds in plausible factors identified in other sources1, 24

From our experience, this immediate postpartum period is very easily disturbed. Any distracting neocortical brain stimulation or the creation of fear has the potential to disrupt the remarkable expansion of the loving relationship between mother and baby that is biologically mediated immediately after birth.¹⁰, ¹² Inappropriate stimulation not only disturbs the tentative process of mother and infant interaction, but also blocks optimal birthing physiology as the sympathetic aspect of the autonomic nervous system is triggered.⁸, ¹², ²⁷ In our experience, inappropriate stimulation of the prefrontal cortex⁸ of the labouring woman includes chatting to her or having an irrelevant conversation near her. We suggest that women, their partners and their support people need to be aware that the woman is still in labour until the placenta is born and her uterus is well contracted. We advise partners against ringing family and friends to announce the birth of the baby as this may inappropriately stimulate the woman or be perceived by the woman as abandonment of her before birth is complete. In our view, these phenomena have the effect of taking her focus away from her inner experience of birthing and loving and predispose her to a PPH. The ideal psychophysiological state for birth is that in which the parasympathetic system, the ‘calm and connection’ also known as the ‘tend and befriend’ system is dominant.¹⁰, ¹¹, ¹², ⁴² Disruptors to this ideal psychophysiological state for third stage include euphoria with an overwhelming sense of relief that the birth is over or anything that triggers sympathetic activation of the autonomic nervous system by causing stress for the woman. We have found that some women find medical equipment, such as a neonatal resuscitation trolley in full view, disturbing, while others may find it reassuring. Other blocks to optimal birthing psychophysiology include: the room being too bright or too cold, phone calls by support people to let people know that the baby is born, strangers entering or ‘busy’ activity, such as cleaning up in the room, any of which can cause the woman to become attentive to external activities or vigilant. Vigilance is one form of fear. The engagement of the neurobiobehavioural state of fear blocks the release of oxytocin and reduces its effectiveness on the uterus, predisposing the woman to atony and subsequent PPH.⁸, ²⁷, ²⁸, ²⁹, ³⁰, ⁴³ With this theoretical framework as a guide, we have identified additional risk factors for PPH (see Table 4) that are generally not recognised by allopathic medicine.

Table 4. Risk factors for postpartum haemorrhage based on midwifery theory. The following factors are thought to interfere with normal physiology and placental birth and should be consider risk factors for PPH. Under any of these circumstances active management of the third stage of labour is recommended⁶, ⁷, ⁹.

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Skills for supporting natural placental birth 

In order to write this section we returned to an early edition of Myles⁴⁴ to capture some of the skills midwives were taught years ago but which are now in short supply.¹⁹, ²¹, ⁴⁵ While Myles described the importance of the physical aspects of third stage care, such as observing for the signs of placental separation: blood show, rising of the fundus of the uterus, cord lengthening while leaving the fundus of the uterus alone, what Myles did not write about was the importance of holistic midwifery care and helping the woman to maintain her mind/body/spirit integration throughout the entire labour and birth.⁴⁴

The aim of Midwifery Guardianship in third stage of labour for healthy women and babies is a holistic one.⁷ The midwifery guardian maintains watchful and positive expectation of a natural physiological placental birth while simultaneously maintaining the primary focus on promoting and supporting maternal–infant love. This focus is important because strong maternal–infant love not only protects the infant and predisposes the mother to take care of the baby, but also optimises birthing physiology, placental birth and haemostasis. Whatever the woman's position, she will have her baby skin-to-skin on her chest. The midwife will notice that the woman is mindful and aware of her body and the ongoing uterine contractions as she observes and responds to her baby's behaviour. The woman will observe the baby's movements as the baby seeks to connect eye-to-eye with her, responds to known voices and displays signs of being ready to breastfeed, such as head bobbing towards the nipple and areola, tongue thrusting and rooting behaviour. It is important to keep the woman and baby warm throughout third stage to optimise comfort and oxytocin production. Keeping the woman and baby warm can be facilitated with the use of warm, dry towels and blankets.

During the third stage, the midwife remains ‘hands off’. She unobtrusively observes for signs of placental separation as outlined above.⁴⁴ Whether or not the signs of placental separation are evident, the adoption of an upright position and recruiting the benefit of gravity may help the woman to feel the placenta coming down the birth canal after several contractions. If the placenta has not been born after approximately 20–30min, some women find it useful to position themselves on the toilet lined with a plastic bag to catch the placenta and any blood loss. We have found that it is important to desist from asking too many questions as this requires engagement of the prefrontal cortex and an evaluation response which takes women out of the birthing biobehavioural state. It is our experience that giving directions in a low toned voice are useful. Directions such as ‘imagine the uterus contracting’ and ‘as the placenta comes down, ready to be born, the pressure in your bottom increases’ and ‘most women like the feeling of the placenta being born’ have been found to be reassuring. These statements do not require self-questioning and therefore prefrontal cortex stimulation, on the part of the woman.

The placenta should be birthed entirely by the woman's efforts and gravity in order for the membranes to come completely and safely off the uterine wall. A couple of DON’TS are required. In natural third stage, leave the uterus alone; DO NOT massage, or meddle with it. It is inappropriate interference in a normal placental birth because meddling with the uterus creates partial separation and bleeding. Likewise, leave the cord alone: DO NOT pull on the cord which, again, can cause partial separation and bleeding and could even invert the uncontracted uterus.⁴⁴ Clinicians are usually advised to limit third stage to 30min.² This advice derives from hospital-based research on third stage which demonstrated that a prolonged third stage is associated with a retained placenta which, in turn, is associated with higher total blood loss.² What does this mean for a woman who has not yet given birth to her placenta after 30min but is not bleeding? Some midwives argue that as long as there is no bleeding, then arbitrary time limits should not be imposed. Both Odent²⁹ and Gaskin⁴⁶ have found that the placenta is usually separated relatively quickly and, in most instances, will be birthed within an hour. This has been our experience too, although occasionally, it may take even longer and yet, blood loss is minimal. In our practice, we have noted that when the placenta has separated, it is often either in the lower segment of the uterus or it has passed through the cervix and is lying in the birth canal. The woman will usually experience this as pressure and perhaps discomfort in the rectum. The woman will, generally, experience strong uterine contractions which increase in intensity the longer third stage takes. In this instance, the midwife will encourage the woman to focus on her bodily sensations and follow the advice given above. In our experience, the majority of women who birth their placentas in a physiological and mindful way relate that the feelings they experience as the placenta comes down through the cervix and vagina are pleasurable ones.

Our description of how a midwife can work with a woman to safely experience a natural third stage of labour is much more holistic than any version of ‘physiological’ or expectant third stage of labour that has been researched to date. See Table 5 for the comparison of our essential elements of Midwifery Guardianship in third stage with those of ‘expectant’ or physiological management as defined by the Cochrane Review.¹⁸ In the absence of higher level evidence, this paper has presented theory and expert opinion to support Midwifery Guardianship during a natural third stage of labour. This represents level 4 evidence of effectiveness.⁴⁷

Table 5. Comparison of Midwifery Guardianship and expectant management in third stage.

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Conclusion 

We have argued that the findings from existing research do not justify routinely interfering in the third stage of labour in births at home or in a birth centre. In this paper we reviewed human psychophysiology and animal physiology to show that a natural and undisturbed labour and birth optimises birthing physiology and mother–infant love. We argue that there are strong psychophysiological grounds to suggest that, for the woman who makes an informed choice to have a natural third stage of labour, it seems prudent to go ahead if all the following safety conditions are met: (1) the woman has given informed consent to birth her placenta in a natural, mindful manner (2) the woman is well prepared and understands that she is still in labour when the placenta is being born; (3) the woman has been healthy in pregnancy; (4) labour and birth of baby have been natural; (5) both the woman and her baby are physically and emotionally healthy at the end of second stage; (6) the birth environment is perceived as safe and supportive by the woman; (7) the attending midwife knows how to act as a Midwifery Guardian and (8) both woman and midwife are willing to utilise an exogenous oxytocic if the situation changes.

We are not claiming that the theory presented here provides a strong evidence-base of safety and effectiveness. We are claiming that the theory of Midwifery Guardianship in third stage labour provides a theoretical framework to conduct research about the relative safety and effectiveness of a psychophysiological approach to the third stage of labour.

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