County Hospitals Establish Strict Policy on Vaginal Births

In a striking departure from practice, doctors at Los Angeles County public hospitals have been forbidden to allow women who have had prior caesarean deliveries to undergo a trial of labor unless they sign a consent form.

The new policy, which went into effect April 1, contrasts starkly with the county’s approach in the late 1980s and early 1990s, when nearly all women giving birth at county hospitals were pushed to deliver vaginally. That rule was eased beginning in 1995 and, as The Times reported, the county has paid out $24 million to settle lawsuits over the deaths and injuries it caused.

The new regulations go further, forbidding vaginal delivery in many cases.

The new policy was developed at the behest of the Board of Supervisors for women who have given birth by caesarean, the highest-risk group. The number of women affected varies from hospital to hospital, but last year at County-USC Medical Center, about 15% of the 4,000 women who came to give birth had had at least one caesarean.

“If they intend for you to do vaginal delivery, you’re going to have to sign the vaginal delivery form,” said Dr. Donald Thomas, the county health department’s director of clinical and medical affairs. “If you don’t, then they can’t do that and they have to do the caesarean.”

Violations of the new policy, Thomas said, can be punished with termination.

“This is a major step forward in protecting the rights and health of women and children,” said county Supervisor Mike Antonovich, who had criticized the earlier practice. “It puts choices back into the hands of the patient.”

Supervisor Gloria Molina, who initially asked that the department develop a written policy, could not be reached for comment. But her spokesman, Miguel Santana, said that “requiring consent is one way to make sure doctors understand their responsibilities to the patient.”

The policy is part of an overall effort to increase accountability among county doctors and avoid malpractice. It comes at a time when some of the nation’s leading experts on vaginal birth are moving away from strongly encouraging natural deliveries for women who have had surgical births.

A recent study showed that women who have had two or more caesareans have a threefold increase in the risk of uterine rupture if they deliver vaginally, compared to women who have had one surgery.

Meanwhile, the toll from the county’s earlier emphasis on vaginal delivery continues to mount. Just this week county lawyers recommended a $650,000 settlement in the case of a 3-year-old boy who was severely injured during his birth at Martin Luther King Jr./Drew Medical Center, the county hospital serving South Los Angeles.

According to a report by county attorneys, the boy, Rudy Lopez, suffers from severe retardation, seizure disorder, cerebral palsy and other neurological problems because doctors allowed his mother to labor for four hours after a caesarean was indicated.

“The delay in performing the caesarean section is directly related to the injuries suffered by Rudy Lopez,” the county’s attorneys wrote in their report.

Rudy was born toward the end of a decade-long period in which doctors in the county’s hospitals avoided performing surgical births, a practice based partly on medical philosophy and partly on finances.

County Health Director Mark Finucane has said that the number of caesareans--surgical births that cost twice as much as vaginal births and require the presence of several physicians, nurses and technicians, as well as the use of an operating room--was “suppressed” because it required a lot of resources.

Perhaps equally significant, the county during those years was at the head of a nationwide movement to reduce the number of caesarean births, which had risen to 40% of all deliveries in some private hospitals. The county’s top obstetricians were in the vanguard of that movement, and made headlines for their success in reducing the number of surgical births to 10%.

But for all the accolades, doctors could not avoid the fact that bad outcomes were increasing.

In a single five-year period reviewed by The Times, the county settled 49 claims involving 53 women and children who were injured or killed as a result of failure or delay in performing a caesarean.

The practice was abandoned beginning in 1995, as severe hospital overcrowding eased. The Lopez case shows that the older approach was still being used at the time.

The new policy forbids attempts at vaginal deliveries for some women, including those whose previous caesareans involved a particular type of incision into the abdomen, a history of uterine problems or uterine surgery, or those who are carrying triplets.

Women carrying large babies, twins or babies who are facing up instead of down, as well as women with vertical incisions in previous C-sections, will be discouraged from attempting labor.