The most commonly prescribed oral narcotics (codeine or hydrocodone with acetaminophen; oxycodone with/without acetaminophen) are all considered L3 in Hale's MMM, and all three are widely used short-term for post-operative pain control.  Of those three, oxycodone is quite likely the most effective analgesic, although MMM references a couple studies indicating that it may concentrate to some degree in breastmilk.  Codeine is actually the medication that was associated with an infant death several years ago; one of its metabolites is morphine, and some people are ultra-rapid metabolizers of codeine, which causes the build-up of morphine that can cause side effects.  And conversely, some people are slow metabolizers of codeine, which makes it less effective for them (in my place of practice, we typically only recommend codeine for kids up to about 12 or so, then oxycodone for everyone else, and never hydrocodone/Vicodin).

When training in adult anesthesiology, I was frankly shocked many times by how little narcotic post-c-section moms often needed, especially in comparison to adults who'd undergone other abdominal surgeries, even minimally invasive laparoscopic ones like appendectomies, gallbladder removals, or hysterectomies.  Based on the size of the abdominal and uterine incisions, it seems completely reasonable to me that many new moms should need oral narcotics for a week or so afterwards, especially considering that they are not able to just sleep for long periods of time and rest the way most people should be able to following major abdominal surgery.  The addition of NSAIDs, particularly ketorolac while inpatient, can greatly help.

The field of pain medicine is relatively new and constantly evolving, and there is so little that we truly know about pain pathways and patients' individual experiences and responses to painful stimuli.  Lea asks about the possibility of pain related to a c-section causing increased pain when breastfeeding.  In my experience, this does not go along with what we currently understand about pain -- there is the concept of hyperalgesia, which occurs when a person experiences *greatly* increased pain in response to a pain stimulus, and treating this condition with escalating doses narcotics usually makes it worse (so how do we treat it???  Good question.... ketamine, dexmedetomidine, etc, no magic bullet yet).  I don't believe that this is seen in a site apart from where the initial injury/insult was, except in some kids we treat that have sickle cell disease.  If a mom had a truly awful, patchy, regional block for her c-section (ie, an epidural that did not completely cover the operative area), and required the addition of adjunct pain medications to make it through the delivery, then that mom might be at a slightly increased risk of having pain issues later on, but that is exceptionally, extremely rare.  I'm just not sure that we can attribute breastfeeding pain to a surgical procedure that occurred prior to it, otherwise we'd be seeing all manner of odd remote pain syndromes following other surgeries.

We usually find that using regional anesthesia for surgery results in a nice preemptive block of pain receptors -- ie, if I plan to place an epidural catheter for post-operative pain control for abdominal surgery in a kid, I will put it in right after we put the child to sleep, so that we can dose it up and use it during the surgery in addition to having the kid remain under general anesthesia.  For some procedures, the surgery becomes more invasive or for whatever reason we elect to put the epidural in at the end of the case before we wake the kiddo up; we will expect that the epidural pain relief post-operatively will not be quite as good as if we had it in place prior to the surgical insult.  If that makes any sense at all....?  I suspect that that concept of preemptive analgesia is why post-c-section moms actually seem to require less narcotics post-operatively than people who undergo other major abdominal operations with just general anesthesia.  

Just my disjointed $0.02 as I lay around on bedrest,
-Sarah Reece-Stremtan M.D. (fledgling pediatric anesthesiologist and inpatient peds pain doc in Washington DC)

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