Pain control after cesarean section (C section) is crucial for the comfort of the new mother. In addition, poor pain control on postoperative day 1 when the mother is mobilizing can hinder her ability to care for her child. The discomfort results from two distinct pathways of nociception: (i) the somatic component derived from the surgical wound, and (ii) a visceral component derived from the ongoing contractions of the uterus. There are also concerns about the development of residual pain after C section. The most commonly used routes for delivering analgesics for postoperative pain control following C section are systemic and neuraxial. Commonly employed medications are opiates, nonsteroidal anti-inflammatory drugs (NSAIDs), and local anesthetics.

Systemic delivery of analgesics traditionally involved intravenous (IV) or intermuscular injection of opiates. It is now clear that the use of the IV route results in more patient satisfaction, overall lowered pain scores, and decreased nursing workload. IV patient-controlled analgesia (IVPCA) results in even higher patient satisfaction scores due to the availability of a more consistent level of analgesia and a greater measure of patient control. Opiate side effects of pruritus, nausea and vomiting, urinary retention, constipation, sedation, and respiratory depression must be monitored and treated accordingly. Although all opiates are present to some degree in breast milk, they have not been shown to be a problem with neonatal sedation. Morphine has the least presence in breast milk. Meperidine, however, is best avoided due to accumulation of its active metabolite in breast milk. It is interesting to note that patients with epidural opiate/local anesthetic infusions had lower pain scores than those with an IVPCA; however, patient satisfaction is still reported to be greater in the IVPCA group.

Neuraxial delivery of opiate analgesics has become more common with the use of spinal or epidural anesthesia for C section. Using neuraxial techniques for the primary anesthetic may help prevent central sensitization with resulting hyperalgesia and allodynia. In fact, residual pain is more prevalent in patients after C section who have had a general anesthetic than those receiving a neuraxial technique. Certain patient factors such as pre-eclampsia, low platelet count, or anticoagulation must be kept in mind when planning a
neuraxial technique. In addition, there is a subset of patients who will refuse neuraxial techniques, and their wishes need to be respected.