Only midwives who have completed the “Opioids and Benzodiazepines: Safe Prescribing for Midwives” course may independently prescribe controlled substances.
A potent semisynthetic narcotic analgesic which binds to opioid receptors in the CNS, inhibiting ascending pain pathways which in turn alters the response and perception of pain.
Indications and Clinical Use:
Hydromorphone may be prescribed by midwives for up to 72 hours postpartum following vaginal and/or operative delivery. It is more potent than morphine by approximately 7-10 times, but used in lower doses. Midwives may only prescribe, order or administer hydromorphone on their own authority for the purpose of short term postpartum pain relief. If a longer course of a pain medication is required, a non-narcotic medication should be prescribed or a referral made to a physician to determine if continued use of hydromorphone seems appropriate. Hydromorphone is the preferred drug of choice over tramadol or acetaminophen/codeine for breastfeeding clients.
For clients with poorly controlled pain, maximum doses of non-narcotic analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs should be considered prior to prescribing a single entity narcotic such as hydromorphone.
Hypersensitivity to hydromorphone or any component found in the formulation. Contraindicated in patients with respiratory depression, acute or severe asthma.
Warnings and Precautions:
May cause CNS depression impairing mental or physical abilities. May cause potentially life threatening respiratory depression. Use with caution in patients with a history of seizure disorder, hypovolemia, cardiovascular disease, substance use. A history of substance use should be considered before prescribing or ordering hydromorphone as it is a highly addictive morphine-type drug and can be abused in a similar manner as other opioid agonists, legal or illicit.
Human Data Suggest Risk
There is a risk of congenital birth defects if exposure occurs during organogenesis. There is a risk of neonatal withdrawal with prolonged in utero exposure. Respiratory depression in the neonate that is similar to that produced by morphine can be expected.
Category L3 – Limited Data- Probably Compatible (preferred narcotic in lactation)
Hydromorphone is considered the preferred narcotic in lactation. This medication does not have an active metabolite and less than 1% of the dose has been found to enter milk. The lowest effective dose should be given for the shortest possible period of time. The neonate should also be monitored for signs of sedation, such as not waking up to feed at regular intervals.
Bradycardia, hyper/hypotension, vasodilation, tachycardia, CNS depression, confusion, dizziness, hallucinations, headache, memory impairment, mood alterations, seizure, GI disturbances.
Dosage and Administration:
For moderate pain: 1-4 mg PO (immediate release) every 4-6 hours PRN
Maximum dose: 9 mg per 24 hours.
Hydromorphone may be prescribed in hospital or in the community. If Hydromorphone is prescribed in the community, a controlled drugs and substances duplicate prescription pad must be used. A prescription cannot exceed three days. No refills.
 Regulator-approved controlled drugs and substances duplicate prescription pads are not yet available for use by midwives.
Onset of Action:
Oral: 15-30 minutes; peak effect: 30-60 minutes
Extended release tablet: 6 hours; peak effect: 9 hours
Adult – Oral extended release: 11 hours
Oral immediate release: 2-3 hours
Time to peak: Immediate release tablet: less than < 1 hour
Extended release tablet: 12-16 hours
Neonate – Unknown
Prescribing extended-release analgesic medication is not within midwifery scope of practice. If a client has been prescribed or is currently taking an extended release prescription medication such as oxycodone or hydromorphone and requires additional pain management in labour or during the early postpartum period, a physician consultation or order is required.