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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 ofrare 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 amedical 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 surgeonestablishes 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 lowtransverse abdominal incision unless anterior position of the placenta necessitates a

posterior hysterotomy, in which case, a midline laparotomy will be required. Afterlaparotomy, the uterus is examined for adequacy of myometrial relaxation andconcentration 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 thefetal 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 importantin 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 anyaccompanying 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).
http://en.wikipedia.org/wiki/Rare_diseasehttp://en.wikipedia.org/wiki/Congenital_disorderhttp://en.wikipedia.org/wiki/Bronchopulmonary_sequestrationhttp://en.wikipedia.org/wiki/Congenital_cystic_adenomatoid_malformationhttp://en.wikipedia.org/wiki/Congenital_cystic_adenomatoid_malformationhttp://en.wikipedia.org/wiki/Teratomahttp://en.wikipedia.org/wiki/Pleuropulmonary_blastomahttp://en.wikipedia.org/wiki/Caesarean_sectionhttp://en.wikipedia.org/wiki/Umbilical_cordhttp://en.wikipedia.org/wiki/Placentahttp://en.wikipedia.org/wiki/Rare_diseasehttp://en.wikipedia.org/wiki/Congenital_disorderhttp://en.wikipedia.org/wiki/Bronchopulmonary_sequestrationhttp://en.wikipedia.org/wiki/Congenital_cystic_adenomatoid_malformationhttp://en.wikipedia.org/wiki/Congenital_cystic_adenomatoid_malformationhttp://en.wikipedia.org/wiki/Teratomahttp://en.wikipedia.org/wiki/Pleuropulmonary_blastomahttp://en.wikipedia.org/wiki/Caesarean_sectionhttp://en.wikipedia.org/wiki/Umbilical_cordhttp://en.wikipedia.org/wiki/Placenta


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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 stepsin 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 theEXIT 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 EXITprocedures 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 feedingtubes 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 rigidbronchoscopy may be necessary to visualize and diagnose abnormal airway anatomy.

Sometimes the glottis can be displaced cephalad above the level of the soft palate inwhich 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 tosecure 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 armouredETT to pass where it could not be before release. Sometimes, airway control is still

impossible even after all these techniques have been tried.


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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 thetrachea 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 thesecond 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 ifneeded, 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 andproper 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 infantshould 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 reversalof 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.


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References

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

(Retrieved on May 17, 2011).

http://www.fetalcarecenter.org/surgery/exit.htm. Fetal Surgery-The ExitProcedure: Principles, Pitfalls, and Progress. Fetal Care Center of

Cincinnati. (Retrieved on May 17, 2011).
http://en.wikipedia.org/wiki/EXIT_procedurehttp://en.wikipedia.org/wiki/EXIT_procedurehttp://www.fetalcarecenter.org/surgery/exit.htmhttp://en.wikipedia.org/wiki/EXIT_procedurehttp://www.fetalcarecenter.org/surgery/exit.htm


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University of Cebu

College of Nursing

Banilad, Cebu City

Reading Assignment

for

Delivery Room-Opon Puericulture Center and Maternity House

Incorporated

Ex Utero Intrapartum Treatment Procedure

( EXIT Procedure)

Submitted by:

Villaceran, Tristan Loyed I.

BSN-3B

submitted to:

Mr. Bernhard Maalat, RN

Clinical Instructor

17 May 2011

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