Chance of rupture prompts move because of potential for malpractice suits

Women who have previously given birth by Caesarean section may have to leave Southern Oregon if they want to attempt a vaginal birth in a future pregnancy.

Three of the four hospitals in Jackson and Josephine counties have stopped offering the option of vaginal birth to women who have previously had a surgical delivery, and the fourth hospital could make a similar decision in January.

Providence Medford Medical Center, Rogue Valley Medical Center and Three Rivers Community Hospital in Grants Pass have imposed a moratorium on vaginal birth after Caesarean, or VBAC.

Ashland Community Hospital will honor existing commitments to several women to deliver vaginally, but the medical staff probably will consider the issue when it meets in January, said hospital spokeswoman Carolyn Johnson.

Patients' safety played a role in the decision, but the potential for expensive malpractice lawsuits was an important factor, said Dr. Jon Gell, medical staff director for Providence and RVMC.
— Complications are rare, but they do happen, Gell said, noting that rupture of the uterus, the main complication in VBAC pregnancies, happens in fewer than one of every 200 such deliveries.

The hospitals' decision affects relatively few women ' Jackson County had 2,250 live births in 2002, and only 38 (1.7 percent) were VBAC deliveries. (RVMC had 22 VBAC deliveries; Providence had four and Ashland had about 12.) But it raises questions about how fears of malpractice lawsuits can influence the practice of medicine, said Dr. Felicia Cohen, chief of obstetrics at Three Rivers Community Hospital.

It's really unfortunate when insurance companies start dictating what happens in medical practice, Cohen said.

It's a travesty that it can't be performed in Southern Oregon.

Although complications are rare, the results are frequently catastrophic. When the uterus bursts, the baby is delivered into the mother's abdomen and can suffer brain damage or death. The infant and the mother may both die without immediate surgery.

Last June, a jury in Pendleton awarded a &

36;10.8 million judgment in a suit that centered on VBAC. The jury ruled St. Anthony's Hospital was negligent and awarded economic damages of &

36;8.8 million as well as non-economic damages of &

36;2 million.

The jury found no negligence or malpractice on the part of the doctor in the case, Cheryl Marier, but she has since dropped obstetrics from her practice, according to Jim Dorigan of Northwest Physicians Mutual Insurance Co.

That suit sent a ripple through the medical community, Dorigan said.

He noted that the American College of Gynecology recently adopted a new standard of care for VBAC delivery which requires a full surgery team (including a surgeon and anesthesiologist) to be immediately available during labor and an operating room kept open. Small hospitals frequently do not have the financial resources to provide that standard of care, Dorigan said.

Northwest Physicians Mutual, a physician-owned company that provides malpractice insurance for many local physicians, will not provide insurance coverage for obstetricians who want to do VBAC unless they meet the new standards of care, Dorigan said.

The hospitals' policy will apply to all women who have had Caesarean deliveries, even if they have since had problem-free vaginal births. He said the statistics about the safety of VBAC delivery have not changed, but the perception of what is acceptable risk has shifted.

It's a real shame for the patients that we can't offer such a basic service that's safe, said Dr. Paul Schroeder, a Medford gynecologist who sees women in their first trimester of pregnancy. He attended VBAC deliveries when he was an obstetrician.

Schroeder related the dilemma he faces with a patient who is now in her 13th week of pregnancy. She had one Caesarean delivery, but would prefer to have her next child vaginally and by all indications she would be an excellent candidate.

Where am I going to refer her? Schroeder said. Who is going to allow her to labor?

Large hospitals that have a surgeon and anesthesiologist on staff 24 hours a day, such as Oregon Health & Science University in Portland, still will be able to offer VBAC, said Dr. Paul Kirk, an OHSU obstetrician.

For us it's easy, Kirk said. We have a resident anesthesiologist. Everybody else has (an anesthesiologist) available, but it becomes a question of what 'immediately available' means.

The local hospitals are not the first to change their policy. Last summer, Merle West Medical Center in Klamath Falls also dropped VBAC deliveries.

Gell, the medical staff director for Medford's two hospitals, said there may be some room for a limited number of VBAC deliveries, but it will take time for the medical staffs and hospitals to develop a plan.

We're not going to do this any more, Gell said, until we figure it out.

Reach reporter Bill Kettler at 776-4492, or e-mail