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.

Authors' conclusions: 

Prophylactic intramuscular or intravenous injections of ergot alkaloids are effective in reducing blood loss, postpartum haemorrhage and the use of therapeutic uterotonics, but adverse effects include elevated blood pressure and pain after birth requiring analgesia, particularly with the intravenous route of administration.

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Background: 

Previous research has shown that the prophylactic use of uterotonic agents in the third stage of labour reduces postpartum blood loss and moderate to severe postpartum haemorrhage. This is one of a series of systematic reviews assessing the effects of prophylactic use of uterotonic drugs - here, prophylactic ergot alkaloids are compared with no uterotonic agents, and different regimens of administration of ergot alkaloids.

Objectives: 

To determine the effectiveness and safety of prophylactic use of ergot alkaloids in the third stage of labour compared with no uterotonic agents, as well as with different routes or timing of administration for prevention of postpartum haemorrhage.

Search strategy: 

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2011).

Selection criteria: 

All randomised or quasi-randomised controlled trials comparing prophylactic ergot alkaloids with no uterotonic agents or comparing different routes or timings of administration of ergot alkaloids in the third stage of labour among women giving birth vaginally.

Data collection and analysis: 

We systematically reviewed the potential studies, considered eligible studies, assessed the validity of each included study and extracted data independently.

Main results: 

We included six studies, comparing ergot alkaloids with no uterotonic agents, with a total of 1996 women in the ergot alkaloids group and 1945 women in the placebo or no treatment group. The use of injected ergot alkaloids in the third stage of labour significantly decreased mean blood loss (mean difference (MD) -83.03 ml, 95% confidence interval (CI) -99.39 to -66.66 ml), postpartum haemorrhage of at least 500 ml (risk ratio (RR) 0.38, 95% CI 0.21 to 0.69) and the use of therapeutic uterotonics (RR 0.25, 95% CI 0.10 to 0.66). The risk of retained placenta or manual removal of the placenta, or both, were inconsistent. Ergot alkaloids significantly increased the risk of elevated blood pressure (RR 2.60, 95% CI 1.03 to 6.57) and pain after birth requiring analgesia (RR 2.53, 95% CI 1.34 to 4.78) but not in vomiting, nausea, headache or eclamptic fit. One study compared oral ergometrine with placebo and showed no significant benefit of ergometrine over placebo. No maternal adverse effects were reported. There were no included trials that compared different administration regimens of ergot alkaloids.

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