Ergot was first de scribed in 1582 but its use was discon tinued in 1828 except for postpartum haem or rhage because of the deaths of mothers and babies, prin cipally due to uterine rupture. The in abil ity to distil the drug from a

coarse organic pre para tion and thus gain more control over its effects was the main reason for this. In the early twentieth century, more ac cur ate distillation was achieved and voices around that time began suggesting that it should be used prophylactically for the third stage (Baskett 2000). Oxytocin was first synthesised in 1955 and was enthusiastically adopted because it did not have the nasty side-effects of ergot. It became extremely pop ular to use in combination with ergot as prophylaxis for the third stage of labour in the West (den Hertog et al. 2001). Interestingly, RCTs only started appearing in the 1980s so the widespread and routine adoption of uterotonics preceded these. Ergot pre para tions are very power ful uterotonics and many childbirth practitioners con sider it a nasty drug with signi fic ant side-effects to be used with extreme caution. Currently its use is either on its own for the control of postpartum haem or rhage or in combination with syntocinon as a prophylaxis for the third stage. Ergot’s unpop ularity is reflected in the fact that many European coun tries no longer use it for third-stage prophylaxis (oxytocin replaces it) (Winter et al. 2007), and the UK is unusual in opting for syntometrine (combination of ergometrine and syntocinon) (Farrar et al. 2009). Postpartum haem or rhage (PPH) is a major cause of maternal mor tal ity in the de veloping world, mainly because pov erty and ill-health leave women profoundly anaemic. Millions are unable to withstand small blood losses in labour. The World Health Organisation ad voc ates active management of the third stage of labour in these settings and has a training programme in operation to institute this policy. Clearly, it is totally inappropriate to argue that physiological third stage should be followed in this con text or in any con text where women carry signi fic ant risks to their health if moderate blood loss is sustained. The key question is: should that apply in every setting?