Exit (Ex-Utero, Intrapartum) Procedure

In select cases where the transition from life in the womb to birth could be dangerous to the baby, a unique form of delivery may be indicated. The ex-utero intrapartum, or EXIT procedure, is designed to allow surgical intervention to be performed while the baby is obtaining oxygen and blood supply from the mother immediately before birth. The EXIT procedure may be recommended in situations such as a baby that is complicated with either a very small chin called micrognathia, or a large mass or tumor on the baby’s neck or face, either of which could make breathing difficult at delivery. Additionally, some large tumors in the baby’s chest could cause significant complications with heart function or breathing at delivery, and it may be recommended to be removed via an exit procedure at the time of delivery.

What happens during a fetal exit procedure?

An exit procedure is both similar and different from a typical cesarean delivery. In an exit procedure, the uterus or womb is kept relaxed with normal blood flow and oxygen flow to the baby during the entire procedure. To achieve this continued blood flow to the uterus and to keep the uterus relaxed, general anesthesia in which the mother is not awake during the procedure is required. After the anesthesia is obtained, a cesarean type incision is made in the mother’s lower abdomen and the uterus is opened with special techniques and instruments to prevent bleeding. The baby is partially delivered but is not removed entirely from the uterus and the umbilical cord is not clamp and cut.

In the case of a suspected obstruction to the babies breathing, a tube is placed into the baby’s trachea or windpipe and proper placement confirmed before the baby is delivered. When an exit procedure is done for a large neck mass, either the tube is placed into the trachea or a surgical airway called a tracheostomy is performed. If neither of these is possible, in very rare cases the neck mass is then surgically removed, and the baby’s airway obtained. Only once the airway or the surgical procedure is confirmed, is the baby completely delivered from the uterus, and the umbilical cord is clamped and cut. In rare cases, such as a large fetal chest mass, during the EXIT after the baby is partially delivery and an IV is started, the pediatric surgeon may make an incision in the baby’s chest and remove the mass. After this is completed the chest is closed and the baby can then be safely delivered. As in a cesarean delivery, the uterus and the mother’s abdomen are then closed.