Friday, December 16, 2016

Expert Panel Q&A at the Amsterdam Breech Conference

First Amsterdam Breech Conference, Day 1
Expert Panel Q&A

Q: I have a question about the article by Thornton et al, referenced by Floortje Vlemmix, that argues that cesarean for breech is clearly beneficial. I have a question about some of the data.
Betty-Anne Daviss answered. (I didn't catch all of her answer, but she discussed the Canadian registry study.)

Q: I have a question about the experience levels of OBs or midwives doing vaginal breeches. Most guidelines suggest experienced practitioners. What do panel members define as experienced? Any factors/parameters that qualify?
Frank Louwen: You have to attend some VBBs, but initially you should watch videos over and over. This is more important than just attending the births. Watch videos: not just the last 10 minutes of the birth, but from the beginning of the labor.

Q: You have to attend many VBBs to be able to identify pathology.
Frank Louwen: We’re always seeing CS and VBB compared without a closer look at the vaginal breeches. What is a real risk for VBB? Once we can point those out, then we can really reduce mortality and morbidity. I've been able to reduce complication rates by more closely looking at the woman and child.
Rebekka Visser: There are cultural differences in hospitals in how they do breeches. For example, what about shoulder dystocia? Some providers have higher instances than others, which points to the complications arising, in part, from what providers are doing. Numbers don’t say everything.
Marjolein Kok: Not many people can speak of real experience here in the Netherlands. You need to know how to solve problems. How? Practice on a mannequin.
Betty-Anne Daviss: We should do a randomized controlled trial on the effects of fear. Fearful people do very crazy, dangerous things. In Canada, we have a 10-15 year break in OBs who used to do VBB, stopped doing it, and then just started doing it again. So they are very fearful because they haven’t done it for a long time, and they act based on that fear. How does fear affect clinical practice?

Q from an OB: Nowadays women are so fearful and anxious to choose a VBB because they worry about regretting it afterwards. How can we counsel women so they have more trust in delivering safely with a VBB? Use other language? Other suggestions how we can counsel women better so they don’t make decisions out of fear or regret?
Andrew Bisits: We do present numbers, but we also are dealing with a generation of women who’ve never been healthier. I’d say this to a woman with a breech baby: “I am confident that I think it would go well for you.” It’s unfortunate that there’s such a fear when, really, whatever we do is safe. We’re dealing with such small numbers now. We’re not going to have a hope in hell unless we do address that. We ourselves need to reclaim confidence in our own skills.
Leonie van Rheenen: Many women have already made their decision by time they come in to see us. Maybe we need a Kim Kardashian who’s done a VBB!

Q: I’m an OB. I've done over 3,000 cesareans and just about 100 VBBs. I am scared with VBBs, even though I do support that choice. Do you support that quote I asked about earlier? (I think he was referencing Thornton et al.)
Frank Louwen: If I had the complication rates reported in the TBT in my own clinic in Germany, I wouldn’t work anymore. I’d be in jail! I am completely convinced that just giving the women the information about the TBT—that they compared different settings, situations, etc—will show that the cesarean was never an answer to complication rates in breech deliveries. It’s not an existing answer for our counseling of women. In Germany, we don’t understand why people are still looking to that trial, as Marek Glezerman pointed out.


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