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The EXIT procedure, or ex utero intrapartum treatment procedure, is a

specialized surgical delivery procedure used to deliver babies who have airway
compression. Causes of airway compression in newborn babies result from a number of
rare congenital disorders, including bronchopulmonary sequestration, congenital cystic
adenomatoid malformation, mouth or neck tumor such as teratoma, and lung or pleural
tumor such as pleuropulmonary blastoma. Airway compression discovered at birth is a
medical emergency. In many cases, however, the airway compression is discovered
during prenatal ultrasound exams, permitting time to plan a safe delivery using the EXIT
procedure or other means.

Process

The EXIT is an extension of a standard classical Caesarean section, where an


opening is made on the midline of the anesthetized mother's abdomen and uterus. Then
comes the EXIT: the baby is partially delivered through the opening but remains attached
by its umbilical cord to the placenta, while a pediatric or neonatal general surgeon
establishes an airway so the fetus can breathe. Once the EXIT is complete, the umbilical
cord is cut and clamped, and the infant is fully delivered. Then the remainder of the C-
section proceeds.

Technique

The decision to enter the abdomen through a low transverse skin incision or
through a midline fascial incision is based on the placental location, predicted site of
hysterotomy and the indication for EXIT. The incision of choice is usually a low
transverse abdominal incision unless anterior position of the placenta necessitates a
posterior hysterotomy, in which case, a midline laparotomy will be required. After
laparotomy, the uterus is examined for adequacy of myometrial relaxation and
concentration of inhalational agents adjusted as necessary.

Before fashioning the hysterotomy, precise sonographic mapping of the placental edge is
crucial to avoid placental injury and hemorrhage. A sterile intra-operative ultrasound is
used to map for the placental borders. This is done while considering the position of the
fetal head and neck to avoid excessive fetal manipulation after hysterotomy. The position
of the hysterotomy is dictated by the placental location.

A low anterior placental site will preclude a low transverse hysterotomy and may
necessitate a posterior approach for the hysterotomy. Special considerations are important
in cases of severe polyhydramnios. Amnio-reduction in these cases is necessary to avoid
underestimation of the proximity of the placental edge to the hysterotomy.

In order to adequately manipulate the fetus, it is sometimes indicated to decompress any


accompanying fetal ascites or cystic mass. This can be achieved using a 20- or 22-gauge
spinal needle under ultrasound guidance. In some instances, the use of amnio-infusion
and fetal version before hysterotomy facilitate the exposure (12).

During EXIT procedures, hysterotomy is done using a specially designed uterine


stapler (U.S. Surgical Corporation, Norwalk, Conn.) to decrease the incidence of bleeding
(13). Following hysterotomy, maintenance of uterine volume is one of the important steps
in an EXIT procedure. This is done to decrease the likelihood of uterine contraction and
placental abruption and thus allow for a continuous maternal-fetal oxygen transfer.

Warm Ringer's lactate solution is infused after the hysterotomy to maintain the
uterine volume and prevent cord compression. Limited exposure of the fetus during the
EXIT procedure also helps in maintaining the uterine volume and fetal temperature. Only
the head, neck and shoulders are exposed while keeping the remainder of the fetus and
the cord intra-uterine.

The most important point in the management of the fetal airway during EXIT
procedures is to be prepared for every contingency. One can never assume that the fetus
will only require direct laryngoscopy and intubation, and so we have developed an airway
algorithm.

In addition to the basic instruments and set-up, the following items should be
available on a separate airway table managed by a second scrub nurse: direct
laryngoscopy supplies with Miller 0 and 00 blades, armoured endotracheal tubes (ETT)
appropriate for the size of the fetus, endotracheal tube exchangers, 2.5 and 3.0 Fr feeding
tubes for surfactant administration, 2.5 or 3.0 rigid bronchoscope, a flexible
bronchoscope, and a major neck tray for formal tracheostomy or mass resection.

Direct laryngoscopy and endotracheal intubation should be the first option for
securing a fetal airway during EXIT procedures.

In cases where there is distortion of the normal anatomy, flexible and / or rigid
bronchoscopy may be necessary to visualize and diagnose abnormal airway anatomy.
Sometimes the glottis can be displaced cephalad above the level of the soft palate in
which case, flexible bronchoscopy via the nares may be helpful. In other cases, mass
effect may shift the glottis severely from its normal midline position.

An armoured endotracheal tube can be placed over the flexible bronchoscope or


rigid lens and can be used to place the ETT beyond the level of obstruction. If this fails to
secure an airway, then retrograde intubation becomes the next option in which a
tracheotomy is performed through limited neck dissection. Using a Seldinger technique,
an ETT exchanger is passed retrograde until seen in the oropharynx and the ETT passed
antegrade over the ETT exchanger and the tracheotomy repaired.

In the case of large neck masses, sometimes traction, by an assistant, of the mass
off the airway will allow an armoured ETT to be passed beyond the level of obstruction.
If there is severe compression, release of the strap muscles will often allow an armoured
ETT to pass where it could not be before release. Sometimes, airway control is still
impossible even after all these techniques have been tried.

In these cases, reflection of the mass off the airway or resection of the mass to
facilitate formal surgical tracheostomy may be necessary. Proper positioning of the
tracheostomy is very important especially in cases of giant neck masses in which the
trachea is pulled out of the chest by neck hyperextension. It is not uncommon to find the
carina at the level of the thoracic inlet due to the opisthotonic position of the head caused
by a neck mass. Care should be taken to place the tracheostomy tube no lower than the
second – third tracheal rings.

After securing the airway, it is prudent to confirm the position of the ETT, or
tracheostomy tube relative to the carina using flexible bronchoscopy. This is particularly
important in cervical or mediastinal masses. Surfactant can then be administered if
needed, by a feeding tube passed through the ETT, and then the fetus is ventilated by
hand.

Finally, umbilical arterial and venous access catheters can be placed and then the
cord is clamped. Coordination between the surgical team and the anesthesiologists is of
paramount importance at this moment to ensure adequate return of the uterine tone and
proper hemostasis. The newborn is taken to an adjoining operating room for either further
resuscitation or to complete the resection of the neck mass. The stability of the infant
should dictate whether this is done or the baby goes to the Neonatal Intensive Care Unit
for further resuscitation and initial management.

Conclusion

The EXIT procedure is an important tool in the management of prenatally


diagnosed congenital malformations. Although it was originally described for the reversal
of tracheal occlusion done in cases of severe congenital diaphragmatic hernias, the period
of uteroplacental bypass it affords can be used in various other settings where cardio-
pulmonary compromise is anticipated. The EXIT procedure provides the surgeon with the
luxury of transforming a potentially fatal neonatal emergency to a controlled environment
to insure a better outcome.
References

http://en.wikipedia.org/wiki/EXIT_procedure. EXIT Procedure. Wikipedia.


(retrieved on January 06, 2010).

http://www.fetalcarecenter.org/surgery/exit.htm. Fetal Surgery-The Exit


Procedure: Principles, Pitfalls, and Progress. Fetal Care Center of
Cincinnati. (retrieved on January 06, 2010).
University of Cebu
College of Nursing
Banilad, Cebu City

Reading for

Delivery Room-Chong Hua Hospital

Ex Utero Intrapartum Treatment Procedure


( EXIT Procedure)

by

Villaceran, Tristan Loyed I.


BSN-2B

submitted to

Ms. Lizly C. Letrondo, RM, RN


Clinical Instructor