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This information was up to date at the time of release to the Heads of Midwifery.
The editorial board does not accept liability for any errors or omissions following its subsequent publication.
Updating arrangements for the formulary should be decided upon and implemented at a local level.
Diamorphine
Patient group Clinical indication
Pregnant women who have requested the administration of opioid analgesia for pain relief during labour.
The relief of pain caused by uterine contractions in labour.
Diamorphine is a pro-drug of morphine that is converted its active components of acetylmorphine and morphine. It is predominantly a central nervous system depressant but has stimulant actions resulting in nausea, vomiting and miosis.
It has a rapid onset of action and duration of about 3-4 hours after IM route.
 POM-midwifemayadministerasmedicineisonmidwives exemptions list
CD – controlled drug
Legal status (GSL, P or POM on exemption list, or PGD)
Pharmacology
(Onset and duration of action where appropriate)
Pharmaceutical form, strength, route of administration
Diamorphine hydrochloride BP 5mg and 10mg ampoules as freeze dried powder, which when dissolved in an aqueous solution is suitable for parenteral administration. (Other strengths are available).
Reconstitute with 1ml of sterile water for injections. For intramuscular injection.
Dose, frequency and maximum number of doses or period of time for administration or supply
The dosage is tailored to the individual patient in accordance with local guidelines.
Consider anti emetic.
Up to 10mg IM (given with IM cyclizine or IM prochlorperazine – see monographs).
Consider a reduced dose in women ≤ 50kg.
A further 2 doses of diamorphine 5-10 mg IM can be given every 4 hours if necessary.
A maximum of 3 doses to be given prior to referral to medical staff.
Contra-indications/exclusion criteria
 hypersensitivity to diamorphine or morphine  women who have refused opioid analgesia  myastheniagravis
 respiratorydepression
 obstructiveairwaysdisease
 biliarycolic
 concurrent use of monoamine oxidase inhibitors or within 2 weeks of discontinuation of treatment
 phaeochromocytoma
 cerebraloedemaheadinjuryorraisedintracranialpressure
Healthcare Improvement Scotland national midwifery formulary
Date of release to Heads of Midwifery and nominated Pharmacist 27 Jan 2020 v3 Page: 1 of 4

Diamorphine
 avoid in acute asthma attack and biliary disorders
 reducedoseinasthmaandreducedrespiratoryreservesincluding severe obesity
 consider reduced dose in impaired renal or liver function, hypothyroidism, adrenocortical insufficiency, urethral stricture, hypotension, shock, inflammatory or obstructive bowel disorders, or convulsive disorders, toxic psychosis, CNS depression, kyphoscoliosis and acute alcoholism
 it can delay gastric emptying and increase the risk of Mendelson’s Syndrome
 check for and document any allergies
 check and document past medical and drug history and current
medication to ascertain potential for overdose  if a caution applies consult with a doctor
 documentconsultationinmaternityrecord
Cautions and action that will be taken if a caution applies
Medicine interactions and action that will be taken if a patient is taking a medicine that may interact
 additive effects with other CNS depressants including alcohol, hypnotics, anxiolytics, tricyclic antidepressants antipsychotics and sedating antihistamines
 increased risk of side effects with anti-cholinergic drugs, potentiation of effects of MAOI’s (refer to BNF), advised to stop for 2 weeks before diamorphine use
 antagoniseeffectsofmetoclopramideanddomperidoneand increase likelihood of constipation with loperamide
 if there is a clinically significant drug interaction, consult with a doctor before administration or supply
 documentconsultationinmaternityrecord
 refer to current BNF for latest information on interactions
Healthcare Improvement Scotland national midwifery formulary
Date of release to Heads of Midwifery and nominated Pharmacist 27 Jan 2020 v3 Page: 2 of 4

Diamorphine
 respiratorydepressionandarrest,circulatorydepression,shock and cardiac arrest
 sedation,nausea,vomiting,constipationandsweating, anaphylactoid reactions
 bradycardiaortachycardia,facialflushing,posturalhypotension and palpitations
 euphoria,dysphoria,weakness,insomnia,dizziness,confusional symptoms hallucinations
 dry mouth, taste alterations, anorexia and biliary spasm
 pruritus,urticaria,skinrashesandcramps
 difficulty with micturition, ureteric spasm, urinary retention,
antidiuretic effect, dependence, raised intracranial pressure and miosis
 on labour – clinical practice suggests that it does not alter the force of contraction in established labour but it may temporarily suppresses uterine activity in early labour. It can delay gastric emptying and may increase the risk of Mendelson’s Syndrome.
 on the neonate – it rapidly crosses the placenta, and severity of side effects depends on the dose and the time between the last dose and delivery. The half-life of diamorphine in the neonate is approximately 14 hours. Respiratory depression, urinary retention, constipation, and drowsiness resulting in poor feeding may occur. All adverse effects can be reversed by naloxone.
 on breast feeding- Nil at the recommended dose. Higher doses and continued use may cause CNS depression and constipation.
 if a serious adverse reaction is suspected please report to the MHRA Yellow Card Scheme http://yellowcard.mhra.gov.uk/
Potential adverse reactions and side effects including actions to be taken if adverse medicine reaction is suspected
Overdose
Action if patient declines
 respiratorydepression,comaandconstrictedpupilsisconsidered indicative of opioid over-dosage with dilatation of the pupils occurring as hypoxia develops
 pulmonaryoedemaisacommoncauseoffatalitiesamong diamorphine addicts
 otheropioidoverdosesymptomsincludecold,clammyskin, hypotension, bradycardia, circulatory failure, muscle flaccidity, severe weakness, severe nervousness or restlessness, confusion, severe dizziness, severe drowsiness, hallucinations, convulsions, rhabdomyolysis progressing to renal failure.
 immediate assessment/treatment is essential – refer to medical staff
 manageinaccordancewithestablishedtreatmentguidelinesor see BNF overdose section
 for further advice contact National Poisons Centre 0344 892 0111  refer to authorised prescriber or doctor
 documentinmaternityrecord
 supplythemanufacturer’spatientinformationleafletifrequested
If diamorphine is ineffective or inadequate discuss alternative analgesia with doctor/GP.
Additional advice and information
Patient monitoring arrangements during and after treatment and follow-up required
Healthcare Improvement Scotland national midwifery formulary
Date of release to Heads of Midwifery and nominated Pharmacist 27 Jan 2020 v3 Page: 3 of 4

Diamorphine
Particular storage requirements –
References
1. SPC for Diamorphine 5mg injection, Dexcel Pharma text revision 16.12.2019, accessed 16.12.19
www.medicines.org.uk