Los Angeles County has paid $24 million to settle 49 claims of mothers and children who died or were injured when county doctors forced poor women to attempt to deliver babies vaginally--even in high-risk cases, according to a review of county and court documents.
The settlements mark the grim cost of the county's leadership in a nationwide movement to reduce the number of costly caesarean sections, a trend that continues to place obstetricians under intense financial and social pressure to reduce the number of surgical births. And although the county has eased its strict rules on caesarean births, taxpayers will go on paying the costs for years to come, while those injured by the policy will bear its human toll for the rest of their lives.
Besides cash, the county settlements reached from 1992 to 1997 have included millions of dollars worth of lifetime health care for the permanently disabled children, a Times review of county and court records shows.
All of the mothers and children were on Medi-Cal.
Two mothers and three infants died. The 46 babies who survived suffer from conditions that include cerebral palsy, mental retardation and paralysis of the shoulder, arm and hand.
The injuries occurred as doctors in the county's mammoth public health care system were carrying out an official policy that directed a trial of labor--an attempt at vaginal birth--for the vast majority of women who came to county hospitals to deliver babies.
Rafael Soto was in the breech position--posterior first--when his mother, Ercida Asuncion Soto, came to County-USC Medical Center to deliver him in 1993. Doctors tried but failed to turn Rafael around so that his mother could safely push him out during labor.
Then, instead of advising Ercida Soto that there were significant risks associated with continuing to deliver vaginally, and that a caesarean section was a safer option, doctors allowed her to continue to labor, according to a report by the county's lawyers.
Rafael was stuck inside the birth canal for so long that he developed severe brain damage and cerebral palsy. He is not expected to live beyond age 10.
The county paid his parents $350,000.
*
The injuries sustained in county delivery rooms are typical of cases in which caesarean sections are not performed in a timely manner, doctors said. County hospitals include County-USC Medical Center, Martin Luther King Jr./Drew Medical Center, Olive View-UCLA Medical Center in Sylmar, and Harbor/UCLA Medical Center.
Two women suffered uterine rupture--including a 21-year-old who had two prior caesareans and whose child, severely brain damaged, is not expected to live beyond age 10. Both women underwent emergency hysterectomies at delivery and cannot bear more children.
Fifteen of the children are mentally retarded, five have cerebral palsy and seven have both.
Four more children are expected to die before age 10, and one will probably have a life span of about 20 years. Two women died.
Ten of the children suffer from paralysis of the shoulder, arm and hand. This common injury results when a baby is too large to pass under the mother's pelvic bone during labor and becomes wedged there.
Labor was ordered for public hospital patients--even in cases where mothers had prior caesareans, despite increased risk of uterine rupture--according to a physician who helped formulate the policy.
Even women who had had two or more caesareans--a group in which the likelihood of rupture of the uterus is three times higher than among those who have had only one--were pushed by county doctors to attempt vaginal deliveries, said Dr. Richard Paul, head of Obstetrics and Gynecology at County-USC Medical Center.
"During that particular time we had a huge crisis with too many patients," Paul said. "So there were things that happened because of a lack of ability to care for all these patients. . . . We were told during those crisis years by county counsel that we could say that everybody gets a trial of labor--without giving the patient an option."
The requirement that nearly all women go through a trial of labor was developed by Paul and other doctors and administrators in the late 1980s, Paul said. Health administrators asked county lawyers in 1992 whether the policy was legal, and were advised that it was, Paul said. The policy "was not the ideal," and was phased out in 1995, he added.
Today, the patient population is down and the hospital's C-section rate hovers around 20%--nearly twice what it was when the policy was in place.
The most common operation for women in the United States, caesarean sections have increased fivefold since the 1960s, when the procedure was used primarily to save the life of the mother. Rates started to climb when doctors began to use it when there were signs that the fetus was in distress.
