EXIT Procedure (Ex Utero Intrapartum Treatment)

An EXIT procedure is a well-organized multidisciplinary treatment plan for mothers and babies in which there are concerns for breathing difficulties at time of delivery. The EXIT is a treatment strategy that uses the mother's placental support to maintain the baby's oxygenation while the doctors assess and treat the baby in order to ensure its breathing capabilities. Although similar to a Cesarean delivery, the EXIT procedure requires special considerations and treatments for mother and baby. There have been several different diseases in which an EXIT procedure has been utilized.

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EXIT procedures are utilized when your doctors are concerned that your baby may not be able to breathe adequately on their own at time of delivery. This can be for several reasons including problems with the lungs or masses of the neck or chest that may be compressing the airway. Such indications have included, but not limited to:

• Large Fetal Neck Masses
• Congenital Diaphragmatic Hernias
• Congenital High Airway Obstructions
• Lung masses
• Chest or mediastinal tumors

The decision to perform an EXIT procedure at time of delivery will be determined by your team of doctors at the Center.

• Type of delivery - EXIT procedures are performed through a Cesarean delivery. A team of adult and pediatric specialist will work together during the procedure to ensure the safety of mother and child.
• Place of delivery - Babies that typically require an EXIT procedure should be cared for at a hospital with adult and pediatric specialists. Because of the concerns with breathing at birth and the potential need for further interventions, this requires specialists that can care for the mother and child at delivery as well as after birth. If the condition requires further surgery, the infant must be in a facility that has neonatal surgical and intensive care capabilities. Therefore, delivery should be in a facility with a neonatal intensive care unit and immediate access to a pediatric surgeon.
• Time of delivery - Because an EXIT procedure is a well-planned strategy amongst many doctors and specialists, your delivery will be scheduled so that the entire team can prepare for the delivery of your baby. If there are no specific reasons to deliver early, your baby will be born at or near term. If the baby's condition deteriorates, earlier delivery may be necessary.

What Will Happen at the Exit Procedure?

The entire team will carefully plan for the delivery of your baby with preparation to perform an EXIT procedure. Although an EXIT procedure utilizes an incision similar to a Cesarean, the goals of an EXIT are very different with special concerns. Instead of stopping blood flow and allowing the placenta to separate from the uterus, an EXIT procedure tries to ensure oxygenation between mother and baby. This maintains the circulation of blood, nutrients, and oxygen to the fetus so that your doctors have time to assess the airway and perform all necessary treatments. Special considerations are made to ensure that mother and child are provided adequate anesthesia. As the infant is delivered, mother and baby are placed on special monitors.At this point, depending on the disease, one of three scenarios may occur.

• EXIT to Airway - Your doctors may assess the airway of your baby a try to place a breathing tube to ensure its ability to breathe. Sometimes, this maneuver can be very difficult or impossible. If your doctors are unable to place a breathing tube other surgical options may be necessary.
• EXIT to Surgery - After your doctors assess the airway and are unable to place a breathing tube, surgery may be necessary to place a breathing tube. A tube can be placed directly into the trachea (windpipe) if it is not able to be passed from the mouth. Occasionally, a large neck mass might prevent the surgical placement of the breathing tube. In this situation, the mass may need to be removed (resected) at the time of delivery while the fetus is still being supported by mother.
• EXIT to ECMO - Depending on the disease, the baby may not be able to breathe properly or obtain enough oxygen despite having an airway. In this case, the baby may require a heart-lung bypass (Extra-Corporeal Membrane Oxygenation (ECMO)) at time of delivery. This will ensure that the proper amount of oxygen is provided to the baby before separation from the mother.

The EXIT procedure is performed in the operating room with all the special equipment necessary to ensure the safety of you and your baby. Afterwards, the mother will be admitted to the Women's Center and the baby to the Neonatal Intensive Care Unit at Children's Memorial Hermann Hospital to monitor for complications. The mother's recovery will be similar to those who undergo regular Cesarean delivery. A pediatric surgeon will evaluate the infant and discuss the next appropriate steps in therapy.

When you contact The Fetal Center, you will be in touch with a dedicated coordinator who will walk you through the process step-by-step and help you to understand every aspect of your care.

The Fetal Center at Children's Memorial Hermann Hospital
UT Professional Building
6410 Fannin, Suite 210
Houston, Texas 77030

Phone: (832) 325-7288
Toll free: (888) 818-4818
Fax: (713) 383-1464
Email: thefetalcenter@memorialhermann.org

Located within the Texas Medical Center, The Fetal Center is affiliated with McGovern Medical School at UTHealth Houston, UT Physicians and Children’s Memorial Hermann Hospital.