2016 Amsterdam Breech Conference
June 30-July 1, 2016

Floortje Vlemmix: Shared Decision Making and Term Breech in the Netherlands

June 30, 2016

Floortje Vlemmix, MD PhD, is a resident OB/GYN at Academic Medical Center in Amsterdam. She wrote her PhD thesis about breech birth in 2008. Her presentation focused on two main topics: shared decision making and the risks of vaginal breech birth. She noted that some of her physician colleagues feel that shared decision making is a farce; it's really just doctors telling women what they should do. But Floortje believes in it. She defines the term as something that "enables you to guide women in their decision on breech delivery."

When she speaks to women about breech birth, she gives them information and asks them to come back and tell her what they'd like. She starts walking them through the risks and benefits. She has to ask herself, "Have I really listened to the patient? Do I know her fears, her desires? Maybe she agreed to the cesarean just because that's what everyone has been telling her."

Floortje discussed how obstetrics is all about preventing perinatal morality and morbidity. Obstetricians need to identify who's at risk, have a diagnosis, and then propose a treatment to prevent the risks. For breech babies, this is crystal clear. We can see if the baby is breech via ultrasound. There's enough evidence to know what the risks are. Citing articles by Thorton 2015 and Vlemmix 2014, she argued that an emergency cesarean is the worst outcome for a breech.

Floortje then posed a question: knowing the data on term breech, is there really a choice? Her conclusion, if you don't take into account subsequent pregnancies, was no. Cesarean section is preferable. See Berhan's 2015 meta-analysis. For example, the perinatal mortality rate for planned vaginal breech is 1.6/1000 compared with 0.5/1000 for planned cesarean section. However, if you include future pregnancies, the planned vaginal cohort had a mortality rate (for the birth after their breech baby) of 1.3/1000, compared with 2.5/1000 with the planned cesarean cohort.

Only two qualitative studies exist about breech birth: one from Switzerland and one from Australia.
Next, Floortje presented Glyn Elwyn's model for shared decision making in clinical practice (2012).
She noted that three decision-making tools for women in the Netherlands are in the works. She called for more decision aid tools tailored to individual women and hospitals. We may not avoid every complication, but we need to try our best to minimize them given the women's decisions.

Comment from Betty-Anne Daviss: In Canada, sometimes we tend to head towards evidence-based medicine, assuming that evidence-based = science. Some cultures or people don't look at science the same way. The Inuit, for example, highly value staying within their communities, so in Canada there are lots of other parameters besides scientific parameters that pregnant women take into account. Science is only one part of the decision-making. And none of those studies that you cited had upright positioning for the vaginal breech births.

Rixa's commentary: Floortje's presentation was a counterpoint to the rest of the conference with her perspective that cesarean section is clearly preferable to planned vaginal breech birth. I was glad that she presented and was willing to enter into a dialogue with people who might not agree with her conclusions. Let's continue to come together and learn from each other!