What is the issue?

The third stage of labour is the period from the 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 death 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 medication (medicine that stimulates contractions), given just before or just after the baby is born to help the muscles of the uterus contract; 2) cord clamping, performed approximately one to three minutes after birth; and 3) the use of controlled cord traction to deliver the placenta in settings where skilled birth attendants are available. This review of studies looked at the use of one group of uterotonic medications called ergot alkaloids (e.g. ergometrine) as part of this active management.

Why is this important?

A previous systematic review showed that the combination of ergometrine and oxytocin was associated with a significantly lower postpartum haemorrhage (PPH) rate (defined as blood loss of at least 500 mL) but a greater incidence of side-effects compared to the use of oxytocin alone. However, there was no review comparing ergometrine with no uterotonic medications and different routes or timings of administration for the prevention of PPH.

What evidence did we find?

We searched for evidence in September 2017 and included eight trials involving 4009 women receiving ergometrine by mouth (orally), into the muscle (intramuscularly (IM)) or into the vein (intravenously (IV)). Of eight trials, seven included studies were analysed in this updated review.

The evidence from the trials analysed suggests that ergot alkaloids may decrease mean blood loss, increase maternal haemoglobin levels in the blood, and may decrease both blood loss of at least 500 mL (PPH) and the use of therapeutic uterotonics. It is uncertain whether ergot alkaloids have any effect on numbers of women experiencing high blood loss of at least 1000 mL (severe PPH). The evidence also suggested that they may increase adverse effects such as increased blood pressure and pain after birth. They may make little or no difference between groups in terms of other adverse effects (vomiting, nausea, headache or eclamptic fit) and results were inconsistent on the risk of retained or manual removal of placenta. Most of the evidence came from trials that administered ergot alkaloids using the IM or IV route. There was only one small trial that looked at the use of oral ergot alkaloids and results were inconclusive. There were limited numbers of included studies and results between studies were not always consistent or precise. Overall quality of evidence across critical and important outcomes ranged from very low to moderate.

What does this mean?

The IV or IM route, although it may reduce blood loss and PPH, was associated with the adverse effects of raised blood pressure and pain due to contractions of the uterus. There was not enough evidence on the oral route of administering ergot alkaloids. There are other medications, namely oxytocin, syntometrine and prostaglandins (which are assessed in other Cochrane Reviews), that can be used and may be preferable.