We routinely use an infusion of local anesthetic/narcotic for post-operative
pain relief following cesarean deliveries.  It usually runs for the first
20-24hr or so and is a sort of "stronger" mix of what we give for labor
analagesia.  If a spinal block is used for the c-section, we will usually
include duramorph as part of the injectate solution.  This provides around
12-18hrs of post-op pain relief, but I've found that it almost universally
does not give as satisfactory results as running the epidural solution
(based unscientifically on the number of phone calls I receive afterwards,
usually in the middle of the night, from nursing staff asking if they can
give other narcotics.)  I can give duramorph via an epidural catheter too,
but then we do not give anything else through the catheter and usually just
remove it after the case once we're sure mom is stable and there won't be
any need for a return to the OR.  But moms don't have as much itching and
seem to just be happier when they've got the infusion going so that's what I
do.  Oh, and duramorph is morphine that's been formulated for neuraxial use,
in case that was unclear here.

I am unsure what the advantage would be of using duramorph AND some kind of
PCEA (patient-controlled epidural analgesia) for post-op pain, when
duramorph's indication and advantage is that it is used on its own.  That's
really not the point, though, as I think the question is whether or not this
type of post-op pain control in general is "better" for moms and babies than
traditional, intravenous medications, such as a morphine PCA.  I don't have
the time here to do a real literature search for this but I am quite sure
that the evidence would support using epidural analgesia instead of IV
narcotics -- I know that in other surgeries such as major bowel operations
using an epidural post-op has been shown to result in earlier return of GI
function and earlier patient mobility.  If I had to guess, I would say that
a more comfortable mom in those first 12-24 hrs post-op can only be a
positive thing as far as helping to get breastfeeding off to a good start
when the delivery has had to be surgical...

Sorry if this is a bit disjointed, let me know if/how I can clarify.  

Fun but freaky breastfeeding-related anecdote of the day:  I've been so
sleep-deprived lately that I recently hallucinated -- to the point that I
screamed, jumped up, and ran to get my husband -- that a thumb-sized beetle
was *biting my nipple.*  In my meager defense my little guy had just nursed
to sleep at bedtime so I was still laying next to him with my shirt hiked up
on his mattress on our floor, I was having very painful vasospasm (just like
an insect bite, right???), and I was quite unsuccessfully fighting falling
off to sleep that early myself.  It wasn't QUITE enough to make me wean the
little guy but it was so close...  

-Sarah Reece-Stremtan M.D. (anesthesiology resident with just 9 1/2 months
to go...)

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