Title : Ex utero intrapartum treatment (EXIT Procedure): An inter-professional and inter-facility collaboration for the management of fetal airway obstruction
Abstract:
Background: Neonatal airway obstruction that is not diagnosed until delivery creates an emergent situation with high morbidity. The antenatal diagnosis of fetal abnormalities allows pediatric and obstetric specialists to manage the compromised neonatal airway in a safe, controlled manner by using the Ex Utero intrapartum Treatment ( EXIT) procedure. The EXIT procedure involves partial delivery of a fetus, allowing continued placental function while the fetal airway is secured. The EXIT procedure requires a coordinated multidisciplinary team including Anesthesiology, Maternal Fetal Medicine, Neonatology, Nursing, Respiratory Therapy, Pediatric Otolaryngology, Pharmacy, Blood Bank, Ultrasound, Surgical Tech Bioengineering, Facilities, and the Mother. The procedure requires the pediatric team to travel to the obstetric facility for collaboration of expertise needed to care for the infant and mother in a safe environment.
Objectives: To establish a multidisciplinary process for safely delivering the fetus with an abnormal airway.
Methods:
• A conference call including all disciplines where all details of plan discussed
• Responsibilities of each discipline outlined and tentative date for procedure set
• Credentials obtained • EXIT planning tool that outlined discipline and equipment needs discussed
• Written Plan of Care made available in Labor Suite
• Calls scheduled to update team on patient’s status, and review details of team and equipment readiness
• Call list established in the event patient presented in labor
• Patient met several team membersprior to procedure
• Schematic of OR space and equipment placement developed
Day of Procedure:
• Walk through by team
• Roles of each person reviewed
• Traffic control-no admittance of non-essential personnel
• Teaching room available to view procedure via closed circuit TV
Outcomes: This procedure has allowed the conversion of a potentially catastrophic birth, where a poor outcome was almost guaranteed, to an orchestrated event with improved outcomes.
Implications: Four EXIT procedures have been done successfully over the last 8 years. The established process has facilitated the procedure even in the setting of personnel and/or physical space changes.
