Probe of Caesarean Policy Is Urged

Calling Los Angeles County hospitals’ past practices unethical, county Supervisor Mike Antonovich on Sunday called for an investigation of a policy under which poor women were forced to deliver babies vaginally, even in high-risk cases--a practice that damaged and ended lives and cost the county millions of dollars in legal settlements.

After The Times’ story Sunday detailing the policy and its consequences, Antonovich compared the now discontinued county policy of requiring “a trial of labor” even in high-risk cases to the infamous Tuskegee experiment in Alabama, in which African American men were denied treatment for syphilis.

“Here it seems we had a similar type of action where the medical profession and the government are jeopardizing a patient’s health,” said Antonovich. He was responding to The Times’ report that detailed $24 million in settlements made to women and children who were injured or killed as a result of failure or delay in performing a caesarean section while the policy was in place.

“This is why it’s so important for the patient and the physician to have contact and a relationship,” Antonovich said. “So the doctor is treating the patient for their well-being, and not to comply with some esoteric theory.”

Antonovich said he will order an investigation at Tuesday’s meeting of the Board of Supervisors into whether other policies at county hospitals mandate a particular course of action instead of taking into account the medical needs and wishes of patients.

The Times reported Sunday that for nearly a decade, from the mid-1980s to the mid-1990s, doctors at county hospitals required all pregnant women to attempt to deliver babies vaginally--even if they had a prior caesarean section, which increases chances that a woman’s uterus will rupture. Vaginal deliveries generally cost half as much as caesareans.

Even women who had two or more prior caesareans, with whom the chances of rupture increase threefold over women who have had just one of the expensive surgical deliveries, were strongly encouraged to attempt labor--and 70% complied.

The policy was implemented at a time when county hospitals were considered leaders in a nationwide movement to reduce the number of caesarean births, which by the late 1980s amounted to 40% of all births at some private hospitals and 24% of births in the United States.

“These women were guinea pigs,” said Miguel Santana, a spokesman for county Supervisor Gloria Molina. “It’s appalling.”

Santana said Molina, who long had wanted to require detailed reports of malpractice cases in county hospitals, had suspected that “something was wrong” when the county was hit with case after case of women and children who were injured by a failure to perform a caesarean or a delay in performing one.

“When we asked the question, we were told that . . . there were not enough doctors to perform caesareans,” Santana said. At Molina’s insistence, the county has implemented several procedures to track and address instances of poor medical care. One requires that confidential reports be sent to each county supervisor before the board votes to settle a lawsuit out of court.

The reports detail what went wrong, and what the Health Department is doing to prevent such problems from recurring. They also detail what disciplinary actions--if any--were taken against the doctors.

The new rules, put into place over the past two years, also require that an experienced staff physician be on hand when any residents--the recent medical school graduates who work at county hospitals to gain experience for licensing--face a difficult delivery.

But the report on one problem delivery--the case of William Portillo, whose arm and shoulder were paralyzed during his delivery at Olive View/UCLA Medical Center in 1993--shows that a caesarean was indicated but was not performed, although an experienced doctor was present.

According to the report, which was obtained by The Times, doctors failed to assess William’s size properly, and therefore did not realize that he was too large to pass under his mother’s pelvic bone.

In fact, William was so large that under the protocols of the American College of Obstetricians and Gynecologists, he should have been eligible for a caesarean birth, in which the mother’s abdomen and uterus are cut open to deliver the baby, according to the report.

In addition, his delivery was so difficult, the report said, that he developed a rapid heartbeat and his mother spiked a high fever.

County doctors attempted three times to use forceps to remove him from the birth canal, and finally resorted to what is called a vacuum extraction. As a result, his neck was twisted and nerves in his shoulder and arm were permanently damaged.

None of the physicians involved in the birth remains on the Olive View staff, according to the report.

According to the report, which was filed in November with a $200,000 settlement recommended in William’s case, county hospitals did not implement a plan to avoid shoulder injuries such as the ones William suffered until 1995, two years after he was born.

That plan requires new residents and medical interns to be given a set of guidelines on methods to extract a baby who becomes stuck. It also required showing them a video on how to do it.

But the plan as described in the report still does not offer caesarean birth as an option when a baby appears too large. And it shows that none of the doctors who took part in the delivery was disciplined.

In the case of Rafael Soto, a baby in the breech, or upside-down position, who was severely injured in a vaginal delivery in 1993, health officials pledged that they would in the future do a better job of detailing the risks of vaginal birth in such cases.

But neither does that report suggest adopting a policy that favors caesarean birth in such cases, despite medical protocols that list the breech position as an appropriate indicator for surgical birth.