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DiamorphineHCl Injection Staff Characteristics Clinical Details Registered Midwife Clinical Situation for which medicine is to be used Pain relief for women in established labour after assessing the level of pain. Clinical Criteria for inclusion Women ≥ 16 years in established labour requesting pharmacological analgesia. Clinical Criteria for exclusion • • • • • • • Management of excluded women and those not wishing to receive care Use in pregnancy or lactation • • Women who have already received another opioid Known hypersensitivity to any component of the medicine. Individuals < 16 years of age Woman with booking weight < 50Kg. Hypersensitivity to Diamorphine or Morphine. Respiratory depression, obstructive airways disease, eclampsia, phaeochromcytoma, hepatic impairment, drug dependence, renal impairment, coma, raised intracranial pressure, biliary colic. Women receiving monamine oxidase inhibitors (e.g. phenelzine, moclobemide) or within two weeks following their withdrawal. Refer to medical staff as appropriate. Document action / refusal in woman’s maternity handheld record. In Pregnancy Administration during labour may cause respiratory depression in the neonate and gastric stasis during labour, increasing the risk of inhalation pneumonia. In Lactation Diamorphine should not be given to women who are breastfeeding as there is limited information available on diamorphine in breast milk. Cautions and/or reasons for seeking further advice from a doctor • • • • • If woman experiencing insufficient pain relief. Woman fits exclusion criteria. Woman suffers an adverse drug reaction. Chronic dosing is required. Woman declines medication. Cautions and action that will be taken if a caution applies • • 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 medical staff. Document consultation in woman’s maternity handheld record. Refer to current BNF for latest information on interactions. Hypotension. Hypothyroidism Asthma (consult with medical staff re:dosage as may need reduced). • • • • • • • • • Hepatic impairment. Renal impairment (consult with medical staff re:dosage as may need reduced). Acute alcoholism. Description of Treatment Name / Form / Strength of Medicine DiamorphineHCl / Powder for Injection / 5mg Dosage Dose according to local Trust guidelines. Route of administration Intramuscular Frequency of administration According to local Trust guidelines. Duration of treatment Duration of labour Legal Status • POMCD – midwife may administer as medicine is on midwives exemption list. Storage requirements • • • Store in Controlled Drug Cupboard. Do not store above 25°C. Keep container in the outer carton. Warnings • A Controlled Drug may not be administered by a student midwife under a midwife exemption. The woman should be checked for excess sedation and for signs of respiratory depression. The drug may cross the placenta and cause neonatal respiratory depression. Caution should be exercised in women with a known history of drug abuse. • • • Follow –up • • Undesirable effects Refer if woman develops side/adverse effects or if there is an inadequate response. Refer immediately in case of overdose. The most serious hazard of therapy is respiratory depression although circulatory depression is also possible. The most common side effects are sedation, nausea and vomiting, constipation and sweating. Other side effects include dizziness, miosis, confusion, urinary retention, biliary spasm, orthostatic hypotension, facial flushing, vertigo, palpitations, mood changes, dry mouth, dependence, urticarial, pruritus and raised intracranial pressure. • If a serious adverse reaction is suspected please report to the MHRA Yellow Card Scheme http://yellowcard.mhra.gov.uk/ Overdose The triad of respiratory depression, coma and constricted pupils is considered indicative of opioid overdosage with dilatation of the pupils occurring as hypoxia develops. • Immediate assessment / treatment is essential – refer to medical staff • Manage in accordance with established treatment guidelines or see BNF overdose section • For further advice contact National Poisons Centres 0844 892 0111 Advice to be given to the woman • • • • Explain treatment and course of action. Side effects explained. Verbal consent obtained before administration. It is good practice to offer the woman the manufacturer’s Patient Information Leaflet to support any verbal advice provided. Monitoring arrangements during and after treatment and follow-up required. Once diamorphine has been administered, the following should be assessed and documented in case notes at 15 minutes intervals until and thereafter for the next 4 hours unless in established labour when observation should be continued as per local Trust guidelines. • Contractions (length, strength, and frequency). • PV loss. • Fetalheart rate. • Effectiveness of diamorphine. • If thewoman suffers a serious adverse drug reaction, seek immediate medical assistance. • Monitor for side effects and effectiveness. • To be reviewed by doctor if inadequate response. Records to be kept Must be written in the once only medicines and pre-medications section of the medicine kardex. The person who writes up the medication must write their designation after their signature e.g. Midwife Band (*). Also record the administration, date, time and name of practitioner in the relevant section of the woman’s maternity handheld record. References • • Diamorphine SPC Wockhardt UK Ltd 31st August 2007 www.medicines.org.uk Guideline for administration of diamorphine as analgesia in labour. Integrated Maternity & Women’s Health Division Guideline Committee Southern Health & Social Care Trust October 2010.