Active management of third stage of labour with ergot alkaloid drugs (e.g. ergometrine)

The third stage of labour is the period from birth of the baby to the expulsion of the placenta and membranes. As the placenta separates, there is inevitably some blood loss from the placental site until the muscles of the uterus clamp the blood vessels. Fit, healthy women cope with this normal blood loss without problems, but where poor nutrition, poor sanitation and limited or no access to clinical care are complications of pregnancy, severe morbidity and mortality can result from excessive blood loss at birth. This is very common in low- and middle-income countries. Active intervention, called 'active management of third stage', is recommended for the third stage of labour to reduce excess blood loss. Active intervention incorporates (1) the administration of a uterotonic drug, given either just before or just after the baby is born to help the muscles of the uterus contract; (2) early cord clamping; and (3) the use of controlled cord traction to deliver the placenta. This review of studies looked at the use of one group of uterotonic drugs called ergot alkaloids, e.g. ergometrine, as part of this active management. The review found six trials involving 3941 women receiving ergometrine by mouth (orally), into the muscle (intramuscularly (IM)) or into the vein (intravenously (IV)). Evidence indicates that the oral route was not very effective. The IV route, although it reduced blood loss, was associated with the adverse effects of raised blood pressure and pain due to uterine contraction, and so is unlikely to be used. The IM route showed benefit in terms of reducing blood loss, and although there were adverse effects similar to those associated with the IV route, these were less common. So, while the ergot alkaloid group of drugs given IM is an option, there are other drugs, namely oxytocin, syntometrine and prostaglandins (which are assessed in other Cochrane reviews), that can be used and may be preferable.