We definitely see the same issue with duramorph, which is why we rarely use it.  When a c-section is performed under spinal anesthetic, duramorph is frequently given (we're talking *tiny* amounts of morphine, like 0.3mg, so considered probably the safest way to get narcotic to mom without much effect on baby).  If duramorph is not given at the time the spinal is placed, really the only option for post-op pain is via IV route, and this is less than ideal as well since usually morphine pca's are started and that much morphine can make mom itchy, drowsy, and just generally uncomfortable.  Nubain, a mixed opioid agonist-antagonist is probably the best treatment for narcotic-induced pruritus but you're right in that it antagonizes some of the analgesic effect of morphine.  If benadryl is used instead, it doesn't work as well and then moms are just very sleepy.

We do most of our c-sections under epidural anesthesia instead, so that we can use the epidural catheter for post-op pain relief with bupivacaine (local anesthetic) + fentanyl (narcotic) for 18-24 hrs.  It usually works really really well although the consensus is that you can get a denser block with a spinal anesthetic (less sensation) as opposed to an epidural and so patients may "feel more" during the surgery when they've gotten an epidural.  I'm not certain though that this type of pain control post-operatively is the best scenario for supporting breastfeeding because moms may still have considerable numbness of their lower half and may not be very mobile even in trying to shift around their bed.

Sigh.  Wish we had a magic bullet for this --- oh wait, I know, how about fewer cesarean deliveries???

And po dilaudid after c-sections???  Interesting idea.  We very rarely use po Dilaudid, I'm not totally sure why, the IV form works very well -- it may have a slightly higher abuse potential (patients *love* the IV stuff) and I believe it is much more difficult to obtain from pharmacies upon discharge from the hospital in comparison with Percocets.

Sarah Reece-Stremtan M.D.
Pediatric anesthesiology fellow in Washington DC who has very happily moved on from doing much OB anesthesia anymore...

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