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The interventions known as ex utero intrapartum treatment (EXIT) are specialized procedures conducted in rare and high-risk cases where securing the fetal airway in utero becomes imperative before delivery. Typically, these procedures are undertaken in fetuses with congenital airway obstructions or cardiopulmonary anomalies that would otherwise lead to fatal outcomes. EXIT encompasses techniques such as establishing an airway, connecting to extracorporeal membrane oxygenation (ECMO), removing masses, or separating conjoined twins while the fetus remains supported by placental circulation. Given the complexity and rarity of these procedures, there are no established guidelines by medical societies emphasizing the need for specialized teams in tertiary care centers. Despite the potential risks involved for both the fetus and the mother, including failure to establish the airway or maternal hemorrhage, the collaborative efforts of interprofessional teams play a crucial role in mitigating these risks and ensuring successful outcomes. Participating in this continuing education activity provides learners with comprehensive insights into the intricacies of EXIT procedures, including their indications, preparatory measures, and the technical skills required for execution. Moreover, it emphasizes the significance of interprofessional collaboration in optimizing patient outcomes. Through this course, participants gain a deeper understanding of the coordinated efforts needed among obstetricians, neonatologists, anesthesiologists, and other specialists involved in the EXIT process. By effectively communicating and working together within a multidisciplinary team, healthcare professionals can enhance their ability to anticipate and address potential complications during EXIT procedures. Objectives: Apply evidence-based techniques and protocols for performing ex utero intrapartum treatment (EXIT) interventions, demonstrating proficiency in establishing fetal airways, connecting to extracorporeal support, or addressing other specific indications under the EXIT umbrella. Implement appropriate preparatory measures for ex utero intrapartum treatment procedures, including ensuring the availability of necessary equipment and coordinating with multidisciplinary teams to optimize patient safety and outcomes.

Apply evidence-based techniques and protocols for performing ex utero intrapartum treatment (EXIT) interventions, demonstrating proficiency in establishing fetal airways, connecting to extracorporeal support, or addressing other specific indications under the EXIT umbrella. Implement appropriate preparatory measures for ex utero intrapartum treatment procedures, including ensuring the availability of necessary equipment and coordinating with multidisciplinary teams to optimize patient safety and outcomes. Select the most suitable approach for ex utero intrapartum procedures based on individual patient characteristics and clinical circumstances, considering factors such as the severity of fetal anomalies and the expertise of available healthcare providers. Apply interprofessional team strategies to improve care coordination and outcomes in patients undergoing ex utero intrapartum treatment procedures. Access free multiple choice questions on this topic.

The ex utero intrapartum treatment (EXIT) procedure represents a rare and high-risk intervention utilized to secure a fetal airway while maintaining placental support before birth. Typically performed for fetuses with congenital airway obstructions or cardiopulmonary malformations, EXIT aims to establish a definitive airway before delivery. This procedure encompasses various techniques, including airway establishment, extracorporeal membrane oxygenation (ECMO), mass resection, and separation of conjoined twins. Due to its complexity, EXIT necessitates interprofessional teams and specialized tertiary care centers. The EXIT procedure was first successfully performed in the United States at the Thomas Jefferson University Hospital in 1990. However, the literature discussed a need for such interventions as early as 1981.[1][2] Since then, the procedure has gained purchase at select centers as a valid option for safely delivering fetuses with antenatally diagnosed airway compromise. The goal of the procedure is to secure a viable fetal oxygenation plan during a cesarean delivery before the umbilical cord is clamped and cut, thereby utilizing the placental circulation to maintain the fetus during the appropriate intervention. The most common indication for an EXIT procedure is a cervical neck mass. Other indications include mediastinal or thoracic masses, congenital high airway obstruction syndrome (CHAOS), congenital diaphragmatic hernia as a second stage after fetoscopic tracheal occlusion, congenital twin separation, and other indications that may differ by institution.[3][4]

The EXIT procedure was first successfully performed in the United States at the Thomas Jefferson University Hospital in 1990. However, the literature discussed a need for such interventions as early as 1981.[1][2] Since then, the procedure has gained purchase at select centers as a valid option for safely delivering fetuses with antenatally diagnosed airway compromise. The goal of the procedure is to secure a viable fetal oxygenation plan during a cesarean delivery before the umbilical cord is clamped and cut, thereby utilizing the placental circulation to maintain the fetus during the appropriate intervention. The most common indication for an EXIT procedure is a cervical neck mass. Other indications include mediastinal or thoracic masses, congenital high airway obstruction syndrome (CHAOS), congenital diaphragmatic hernia as a second stage after fetoscopic tracheal occlusion, congenital twin separation, and other indications that may differ by institution.[3][4] Generally speaking, the procedure consists of hysterotomy and delivery of the head, neck, and torso of the fetus until the area of interest is fully exposed. The definitive procedure is then carried out, which could be anything from intubation to tracheostomy to even resection of the offending lesion. The umbilical cord is then cut, and the fetus is delivered. Coordination is of utmost importance in these cases, as safely accomplishing an EXIT requires no less than 2 anesthesia teams, 2 to 4 surgical subspecialties, and 2 surgical sets with their attendant technicians and nurses.[3][5][6] Because the risks to the mother and fetus are so high, cases that may benefit from this procedure must be referred to the appropriate centers early. The family and all treating specialties should be involved in face-to-face risk and benefit discussions, ideally in an interprofessional conference format. The overall number of these cases is increasing as our ability to diagnose and anticipate disastrous fetal airways has advanced with improvements in imaging and prenatal testing. However, EXIT procedures are still rare and only performed at select institutions.[7]

Maternal Complications The primary maternal risk during EXIT is hemorrhage. Predisposing factors include prolonged uterine relaxation, larger hysterotomy than standard cesarean delivery, and a higher likelihood of placental injury. Despite this, results from retrospective studies have shown that only 6% of mothers require intraoperative blood transfusion. The risk of surgical site infection is also higher than a standard Cesarean delivery at 15% versus 2%, respectively, because of prolonged operative time. A decrease in future fertility and increased risk of uterine complications in future pregnancies were thought to be long-term risks of the procedure, but studies have not supported this.[6][30] Fetal Complications Intrapartum risks to the fetus are mainly related to cardiac dysfunction secondary to maternal anesthetic overdose, maternal hypotension leading to placental hypoperfusion, direct injury to the placenta or placental abruption, and cord compression.[31] Risks of mass resection include nerve or vascular injury, bleeding, and surgical site infection. The inability to secure the airway and fetal demise are the most significant risks. The incidence of these complications is not currently well reported in the literature.

The EXIT procedure demands high interprofessional collaboration among physicians, advanced practitioners, nurses, pharmacists, and other health professionals to optimize patient-centered care, outcomes, patient safety, and team performance. This complex operation necessitates secure communication and physical cooperation among clinicians, alongside skillful support staff participation from various roles such as nurses, surgical technicians, and radiology technicians. Enhancing teamwork and outcomes involves several specific measures, including interprofessional meetings with the patient before the procedure to ensure comprehensive care planning, rehearsal of the procedure to familiarize team members with their roles and responsibilities, and efforts to maintain continuity of team members from procedure to procedure to preserve team chemistry and efficiency. By fostering effective interprofessional communication, coordination, and collaboration, healthcare teams can ensure the safe and successful execution of EXIT procedures, ultimately improving patient outcomes and satisfaction.