Budget Cuts to Be Felt in Pain of Childbirth

In the labor and delivery unit of Olive View-UCLA Medical Center, budget cuts will mean real pain. Specifically, the layoffs of two obstetrical anesthesiologists will mean more painful childbirths.

The reason, said Dr. Larry Evertson, head of Olive View’s obstetrics division, is that fewer women will get an epidural during labor--a pain-alleviating procedure that, in effect, is already rationed to just 40% of those who have their babies in the unit, a much lower percentage than in most private hospitals.

It’s just one example of the sacrifices that will be made as doctors and administrators grapple with deep cuts in health-care funding due to Los Angeles County’s fiscal crisis.

Labor and delivery is just one unit of one department in the stricken health-care system, where 5,200 employees were given notices Friday that they would lose their jobs. Obstetrics is not even the hardest-hit department. Some services, such as the hospital’s satellite clinics, were eliminated outright. But the department offers a glimpse of how even non-crippling cuts could result in significant changes in patient care.

Without an anesthesiologist on hand to perform epidurals, doctors must rely instead on less-effective, old-fashioned methods such as doses of narcotics, Evertson said. An epidural may not be considered strictly necessary, but “I hesitate to call it a luxury,” said Evertson, showing quiet anger.

During a lull between births Saturday, Evertson talked about the complexities of applying budget directives that look simple on paper to the flesh-and-blood reality of treating patients. He predicted the cuts will result in referrals of more high-risk births to other hospitals, less time for preparing new mothers, delayed Cesareans, and in some cases, higher risks to babies and mothers.

“This [department] is a safety valve for the system out there,” he said. “These patients will not go away. . . . They will just show up someplace else.”

Olive View’s obstetrics department handles 10,000 patient visits per year, and on average delivers more than a dozen infants per day. One-fifth of these are considered high-risk cases.

The department also includes a neonatal intensive-care unit where about 15 premature and sick newborns lie, some nestled in Saran-Wrap-like plastic, breathing through respirators, tape over their eyes.

The department reels between frantic activity and peaceful lulls: No schedule dictates when, or how many, mothers-to-be will show up in labor. Occasionally, more than one baby comes into the world at one time. Doctors and nurses then run back and forth between delivery rooms.

Cuts in the department include about 30 of approximately 170 positions in the nursing staff, three midwives, and a physician who specializes in treating sick newborns. Evertson also had to lay off four of 12 young obstetricians who are to be replaced by doctors with more seniority, transferred from elsewhere in the health-care system.

As he assessed the damage, Evertson kept coming back to the anesthesiologists.

Budget cuts have been tailored to preserve the most necessary services at the expense of those deemed less so. Because obstetrics will still be able to summon general anesthesiologists from other areas of the hospital in emergencies, the positions were cut.

But Evertson argued the line between the necessary and the expendable is not so easily drawn when it comes to delivering babies.

For one thing, the two doctors who provided these services in his department were specialists, and had a deep interest in improving care. When they were brought on board, they increased the number of women receiving epidurals at Olive View by more than a third, he said.

An epidural--allowing for continual release of a local anesthetic through a needle in the back--is among the best means for reducing labor pains. Although a few women forgo them by choice, most want them if the option is given, Evertson said. But obstetricians alone cannot administer the procedure without risk to the patient, not to mention considerable legal risk to themselves.

Unless Evertson is able to secure the transfer of a new obstetrical anesthesiologist, epidurals will be limited only to emergency cases, he said. Anesthesiologists will still be available for Cesarean deliveries, but they will have to be brought in from other departments.

This also worries Evertson. He wonders about those cases when a Cesarean needs to occur immediately, such as when an umbilical cord is wrapped around a baby’s neck. “If you wait 10 minutes, it may be too long,” he said. He added matter-of-factly: “You will lose a baby once in a while because of this.”

Overall, hospital administrators said the layoffs caused little immediate disruption Saturday, with nearly all employees showing up as usual, including those who were told their jobs would end Oct. 1. But Evertson was not the only one who seemed weighed down, even as he worked.

Karen Gray, a midwife in the obstetrics unit, learned Friday that she and one other midwife will be transferred. A third was laid off, leaving no midwives in the obstetrics department. Among the functions of the midwives is educating new mothers on how to breast-feed and bathe their infants.

It’s a job that can’t be condensed into a few minutes: “It takes 20 or 30 minutes to start to breast-feed,” Gray said. “You have to be there with them, get them to hold the baby, tickle the baby’s feet,” she said.

Relief nurse Kelly Moulton retained her job, but said many nurses in the department were pessimistic on their futures there.

Evertson gave other examples of how the disruption of the cuts involves more subtleties than simply the elimination of some services.

For instance, his four obstetricians are being replaced by transfers. But one of the replacements is an obstetrician who has been working in an outpatient clinic. “He doesn’t do deliveries. He hasn’t done them for years,” Evertson fretted. And this is a unit that specializes not only in deliveries, but in high-risk deliveries where lives of mothers and babies may be at risk.

Evertson said cutting back to a single physician for sick and premature babies is also problematic. “It’s hard for someone to work 24 hours a day,” he said.

Someone has to be responsible for the 15 babies in the neonatal intensive-care ward, some of whom are so small you could hold them in cupped hands. And new arrivals to this ward might come at 3 a.m. The remaining ward physician neonatalogist will now be on call all the time, Evertson said.

Evertson said he is still enthusiastic about the clinic, but now finds himself absent-mindedly thumbing through want ads for doctors. “I guess it has to get so bad it affects a large number of people.”