County Adopts New Rules on Caesareans

In a striking departure from prior 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 suits over the deaths and injuries it caused.

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

The new policy was developed for women who have previously given birth by caesarean--the highest risk group--at the behest of the Board of Supervisors. The number of women affected varies from hospital to hospital, but last year at County-USC Medical Center, for example, about 15% of the 4,000 women who arrived to give birth had had at least one prior 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 was outspoken in his criticism of the earlier practice. “It puts choices back into the hands of the patient.”

The policy comes at a time when some of the nation’s leading experts on vaginal birth after caesarean section are moving away from strongly encouraging natural deliveries for women who have had previous 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 try to deliver vaginally than women who have had just one prior 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 King/Drew Medical Center, the county hospital serving South Los Angeles.

The boy, Rudy Lopez, suffers from severe retardation, seizure disorder, cerebral palsy and other neurological problems because doctors at the hospital 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 a report on the case.

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 was resource-intensive.

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 of promoting vaginal births 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.

In Rudy’s case, for example, after the decision was made to give his mother a caesarean, an hour passed before he was delivered. Under the new rules, any doctor who waits more than 30 minutes could be fired.

Further, the policy forbids outright attempts at vaginal deliveries for some women, including those whose previous caesareans involved a particular type of incision into the abdomen, or a history of uterine problems or uterine surgery, or 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, a significant change from the procedures of the early 1990s.

“It’s the most conservative approach” that the county has taken toward vaginal delivery, Thomas said.