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<script type="text/javascript" src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.boots.min.js"> </script><title>Ex utero Intrapartum Treatment (EXIT) Procedure - StatPearls - NCBI Bookshelf</title>
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<meta name="citation_date" content="2024/05/25">
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<meta name="citation_author" content="Russell De Jong">
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<meta name="citation_author" content="Taylor Fordham">
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class="title" itemprop="name">Ex utero Intrapartum Treatment (EXIT) Procedure</span></h1><p class="contribs">De Jong R, Fordham T.</p><p class="fm-aai"><a href="#_NBK604209_pubdet_">Publication Details</a></p></div></div><div class="jig-ncbiinpagenav body-content whole_rhythm" data-jigconfig="allHeadingLevels: ['h2'],smoothScroll: false" itemprop="text"><div id="article-161554.s1"><h2 id="_article-161554_s1_">Continuing Education Activity</h2><p>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.</p><p>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. </p><p>
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<b>Objectives:</b>
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<ul><li class="half_rhythm"><div>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.</div></li><li class="half_rhythm"><div>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.</div></li><li class="half_rhythm"><div>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.</div></li><li class="half_rhythm"><div>Apply interprofessional team strategies to improve care coordination and outcomes in patients undergoing ex utero intrapartum treatment procedures.</div></li></ul>
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<a href="https://www.statpearls.com/account/trialuserreg/?articleid=161554&utm_source=pubmed&utm_campaign=reviews&utm_content=161554" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Access free multiple choice questions on this topic.</a>
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</p></div><div id="article-161554.s2"><h2 id="_article-161554_s2_">Introduction</h2><p>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. </p><p>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.<a class="bibr" href="#article-161554.r1" rid="article-161554.r1">[1]</a><a class="bibr" href="#article-161554.r2" rid="article-161554.r2">[2]</a> 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.<a class="bibr" href="#article-161554.r3" rid="article-161554.r3">[3]</a><a class="bibr" href="#article-161554.r4" rid="article-161554.r4">[4]</a></p><p>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.<a class="bibr" href="#article-161554.r3" rid="article-161554.r3">[3]</a><a class="bibr" href="#article-161554.r5" rid="article-161554.r5">[5]</a><a class="bibr" href="#article-161554.r6" rid="article-161554.r6">[6]</a> 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.<a class="bibr" href="#article-161554.r7" rid="article-161554.r7">[7]</a> </p></div><div id="article-161554.s3"><h2 id="_article-161554_s3_">Anatomy and Physiology</h2><p>
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<b>Maternal Anatomy</b>
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</p><p>Multiple anatomical layers must be traversed for the surgeon to gain access to the uterus.<a class="bibr" href="#article-161554.r8" rid="article-161554.r8">[8]</a> The skin and subcutaneous tissues give way to reveal the vertically oriented rectus abdominus muscle fibers, which are joined by an avascular aponeurosis in the midline. Next is the parietal peritoneum, which directly overlies the gravid uterus. Adhesions involving the peritoneum, omentum, bowel, bladder, and other intraperitoneal structures are present in patients who have undergone previous surgeries, especially cesarean delivery.</p><p>The uterus is a muscular organ comprising 3 layers: the serosa or perimetrium, the myometrium, and the endometrium, from superficial to deep, respectively.<a class="bibr" href="#article-161554.r9" rid="article-161554.r9">[9]</a> The uterine arteries and veins, stemming from the internal iliac vasculature, run along the lateral surfaces of the uterus and anastomose with the ovarian vessels that stem from the abdominal aorta. These vessels may be at high risk of injury during an EXIT procedure performed for fetal mass due to anatomical distortion secondary to the mass and the need for extended hysterotomy. Injury to these vessels poses a significant threat to the completion of the procedure, as the flow through them is increased 8-fold during pregnancy.<a class="bibr" href="#article-161554.r10" rid="article-161554.r10">[10]</a> The uterine artery lies just superficial to the descending ureter, another relationship that is a source of potential complication during this surgery, though not as emergent as iatrogenic hemorrhage.</p><p>The placenta is located within the endometrial cavity, the site of all nutrient and gas exchange between fetus and mother. Most commonly, the placenta is found implanted on the superior wall of the endometrial cavity, also known as fundal implantation.<a class="bibr" href="#article-161554.r11" rid="article-161554.r11">[11]</a> The placenta implants on the anterior wall approximately 25% of the time and, therefore, could be threatened by hysterotomy. Placental location is critical to note in the setting of EXIT, as preservation of the placenta and, thus, fetal circulation is an absolute requirement for success. The amniotic sac is encountered after the hysterotomy is complete; the division of this structure removes the last barrier to fetal delivery.</p><p>
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<b>Fetal Anatomy</b>
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</p><p>Following the axiom, "children are not small adults," the fetal and neonatal airways require distinct knowledge and skills to manage successfully. The neonatal head is approximately 2 times larger in proportion to the body than an adult, resulting in neck flexion and, therefore, airway compromise when fully supine.<a class="bibr" href="#article-161554.r12" rid="article-161554.r12">[12]</a> Conversely, overextension of the neck with a large shoulder roll or other such positioning can narrow the airway as the soft tissue stretch compresses the soft tracheal and laryngeal cartilages.</p><p>The entire larynx is tilted anteriorly, and the tongue base is relatively larger, leading to more severe obstruction by tongue relaxation posteriorly. The airway is also more funnel-shaped than an adult airway, with the narrowest portion being the circular or near-circular cricoid cartilage.<a class="bibr" href="#article-161554.r13" rid="article-161554.r13">[13]</a> Some debate exists over whether neonatal cricoid cartilage is more often elliptical or circular.<a class="bibr" href="#article-161554.r14" rid="article-161554.r14">[14]</a><a class="bibr" href="#article-161554.r15" rid="article-161554.r15">[15]</a> A neonate with a large cervical or intrathoracic mass can significantly alter the narrowest airway site. The entire laryngeal structure is also higher in the neck than in the adult, with the glottis lying approximately at the third cervical vertebrae rather than the fourth or fifth.</p><p>The laryngeal cartilages are also shaped and angled differently than an adult's. The epiglottis is proportionately longer, more curled into a "U" or omega (Ω) shape, and angled posteriorly over the glottis. The arytenoid, corniculate, and cuneiform cartilages are proportionately larger, and the aryepiglottic folds are nearer to the midline. The cartilages are also more pliable and, thus, more susceptible to external compression.<a class="bibr" href="#article-161554.r16" rid="article-161554.r16">[16]</a> Should endotracheal intubation be pursued, the tube size selection is generally based on weight. Cuffless tubes are used even during positive pressure ventilation due to the funneling of the neonatal airway, with the narrowest point at the cricoid.</p></div><div id="article-161554.s4"><h2 id="_article-161554_s4_">Indications</h2><p>The EXIT procedure was first described in 1997 as a second stage after fetoscopic tracheal clipping or balloon occlusion was performed to treat severe congenital diaphragmatic hernia.<a class="bibr" href="#article-161554.r17" rid="article-161554.r17">[17]</a> As techniques have advanced, so has the list of indications. Chronologically, the procedure has been performed for securing the airway in congenital neck masses with or without mass resection at the time of EXIT, congenital high airway obstruction syndrome (CHAOS), establishment of extracorporeal membrane oxygenation (ECMO) cannulas, and emergency separation of conjoined twins.<a class="bibr" href="#article-161554.r4" rid="article-161554.r4">[4]</a><a class="bibr" href="#article-161554.r18" rid="article-161554.r18">[18]</a><a class="bibr" href="#article-161554.r19" rid="article-161554.r19">[19]</a><a class="bibr" href="#article-161554.r20" rid="article-161554.r20">[20]</a><a class="bibr" href="#article-161554.r21" rid="article-161554.r21">[21]</a><a class="bibr" href="#article-161554.r22" rid="article-161554.r22">[22]</a></p><p>
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<b>Airway Obstruction</b>
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</p><p>Congenital neck masses that may cause airway obstruction, necessitating treatment include:</p><ul><li class="half_rhythm"><div>Neck masses</div></li><li class="half_rhythm"><div>Congenital high airway obstruction syndrome </div></li><li class="half_rhythm"><div>Airway atresia or stenosis</div></li><li class="half_rhythm"><div>Micrognathia</div></li><li class="half_rhythm"><div>Removal of tracheal clip or balloon <a class="bibr" href="#article-161554.r4" rid="article-161554.r4">[4]</a><a class="bibr" href="#article-161554.r22" rid="article-161554.r22">[22]</a></div></li></ul><p>
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<b>Mass Resection</b>
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</p><p>Fetal masses in which resection is performed to relieve obstruction include:</p><ul><li class="half_rhythm"><div>Neck masses</div></li><li class="half_rhythm"><div>Intrathoracic mass or malformations</div></li><li class="half_rhythm"><div>Sacrococcygeal teratomas <a class="bibr" href="#article-161554.r4" rid="article-161554.r4">[4]</a></div></li></ul><p>
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<b>Extracorporeal Membrane Oxygenation Cannula Placement</b>
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</p><p>Conditions that have required cannula placement for ECHO include severe congenital heart diseases and diaphragmatic hernias.<a class="bibr" href="#article-161554.r4" rid="article-161554.r4">[4]</a><a class="bibr" href="#article-161554.r22" rid="article-161554.r22">[22]</a></p><p>
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<b>Separation of Conjoined Twins</b>
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</p><p>Radiographic evaluation to assess the need for a complete EXIT procedure in patients with neck masses has been attempted, as some patients can be delivered vaginally and supported noninvasively or with standard intubation via direct laryngoscopy. The tracheoesophageal displacement index (TEDI) was proposed as a predictive radiological measure that could predict the degree of airway complication and, therefore, the need for EXIT.<a class="bibr" href="#article-161554.r23" rid="article-161554.r23">[23]</a> TEDI is defined as the sum in millimeters of the lateral and ventral displacement of the tracheoesophageal complex from the ventral aspect of the cervical spine as measured on axial magnetic resonance imaging (MRI). The eponymous study found that a TEDI of >12 mm correlated with a complicated airway, as did teratoma pathology, polyhydramnios, and the largest diameter of the mass being 12 mm or more. More extensive retrospective studies and systematic reviews have validated these factors as reliable indicators for EXIT, expanding them to include solid tumors in general and an absent stomach bubble.<a class="bibr" href="#article-161554.r7" rid="article-161554.r7">[7]</a></p></div><div id="article-161554.s5"><h2 id="_article-161554_s5_">Contraindications</h2><p>As an extension of the work exploring radiographic indications, scenarios less likely to need EXIT have also surfaced. A systematic review found that lymphatic malformations, neck masses <3.5 cm, and any size fetal neck masses without anatomic compression or airway displacement are unlikely to present complications needing more than standard intubation after delivery. Therefore, these are relative contraindications to EXIT.<a class="bibr" href="#article-161554.r7" rid="article-161554.r7">[7]</a> Depending on the confidence and experience of the resuscitation team, the airway surgeon may still be requested in the delivery suite to be ready for bronchoscopy or tracheostomy after delivery. Hard contraindications include any congenital anomaly that indicates fetal nonviability.</p></div><div id="article-161554.s6"><h2 id="_article-161554_s6_">Equipment</h2><p>The required equipment for an EXIT procedure can vary significantly based on the evaluation performed during the workup phase and the planned EXIT type. Given the mother's open surgical site, the airway equipment must be kept sterile in these circumstances. Generally, all EXIT procedures require the following equipment:</p><ul><li class="half_rhythm"><div>Anesthesia circuits for both mother and fetus with invasive maternal blood pressure monitoring</div></li><li class="half_rhythm"><div>Foley catheter</div></li><li class="half_rhythm"><div>Two large-bore peripheral intravenous lines</div></li><li class="half_rhythm"><div>Type-and-crossed blood for possible maternal transfusion in the room</div></li><li class="half_rhythm"><div>Possible epidural catheterization</div></li><li class="half_rhythm"><div>Ultrasound machine with a sterile sleeve</div></li><li class="half_rhythm"><div>Cesarean delivery surgical set</div></li><li class="half_rhythm"><div>Electrocautery</div></li><li class="half_rhythm"><div>Uterine stapling device</div></li><li class="half_rhythm"><div>Amnioinfusion</div></li><li class="half_rhythm"><div>Fetal resuscitation bay</div></li><li class="half_rhythm"><div>Optional adjacent operating room set up ready to receive infant</div></li></ul><p>EXIT-to-resection and EXIT-to-separation of congenital twins may require additional surgical equipment specific to the procedure being performed. EXIT-to-ECMO procedures require an ECMO unit and trained support staff. EXIT-to-airway procedures may also require the following supplies:</p><ul><li class="half_rhythm"><div>Pediatric airway cart
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<ul><li class="half_rhythm"><div>Pediatric laryngoscopes</div></li><li class="half_rhythm"><div>Endotracheal tubes: 3.0 mm cuffed, 3.0 mm uncuffed, 2.5 mm uncuffed</div></li><li class="half_rhythm"><div>Pediatric airway cart with supplies for direct laryngoscopy and removal of tracheal clip or balloon if indicated</div></li></ul>
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</div></li><li class="half_rhythm"><div>Pediatric tracheostomy tray</div></li></ul></div><div id="article-161554.s7"><h2 id="_article-161554_s7_">Personnel</h2><p>Ideally, the following specialists and staff are part of a designated team that performs these procedures together whenever needed in this high-pressure environment; team cohesion could be the difference between success and failure. Team members are specialized in caring for maternal or fetal patients, including the following:</p><ul><li class="half_rhythm"><div><b>Maternal team</b>
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<ul><li class="half_rhythm"><div>Obstetric anesthesiologist</div></li><li class="half_rhythm"><div>Obstetrician</div></li><li class="half_rhythm"><div>Circulating nurse</div></li><li class="half_rhythm"><div>Surgical technician</div></li></ul>
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</div></li><li class="half_rhythm"><div><b>Fetal team</b>
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<ul><li class="half_rhythm"><div>Neonatal anesthesiologist</div></li><li class="half_rhythm"><div>Pediatric surgeon</div></li><li class="half_rhythm"><div>Pediatric otolaryngologist</div></li><li class="half_rhythm"><div>Neonatal intensivist</div></li><li class="half_rhythm"><div>Possible ECMO team</div></li><li class="half_rhythm"><div>Possible pediatric cardiology or cardiothoracic surgery</div></li><li class="half_rhythm"><div>Circulating nurse</div></li><li class="half_rhythm"><div>Surgical technician</div></li></ul>
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</div></li></ul></div><div id="article-161554.s8"><h2 id="_article-161554_s8_">Preparation</h2><p>Once a mother and fetus are identified as candidates for the procedure, expeditious referral to a center practicing EXIT should be pursued. A thorough prenatal workup should be conducted to give the parents and treating team the information to make the best decision regarding a treatment plan. Early identification of features such as polyhydramnios and hydrops fetalis, which increase the risk of preterm delivery, is essential as a key to successful EXIT, a planned, controlled procedure before spontaneous labor and delivery ensue.<a class="bibr" href="#article-161554.r24" rid="article-161554.r24">[24]</a></p><p>Imaging in preparation for EXIT procedures typically begins with ultrasonography to characterize most lesions necessitating the procedure. Ultrasonography can also visualize placental anomalies that may make hysterotomy difficult or dangerous. More advanced 3- and 4-dimensional ultrasounds and fetal MRIs are often used to work up the anomaly further once the patients reach a tertiary care center.<a class="bibr" href="#article-161554.r25" rid="article-161554.r25">[25]</a><a class="bibr" href="#article-161554.r26" rid="article-161554.r26">[26]</a> Even more advanced options include virtual bronchoscopy, in which a 3-dimensional video of the fetal airway is built from MRI imaging, or a 3-dimensional printing of the airway. Fetal tracheoscopy is a rare invasive option in which the airway is directly examined through a trans-placental trocar. Interventions have also been performed this way, including intubation with a standard 2.5 mm endotracheal tube.<a class="bibr" href="#article-161554.r27" rid="article-161554.r27">[27]</a><a class="bibr" href="#article-161554.r28" rid="article-161554.r28">[28]</a></p><p>Preparing the operating room and the involved medical and surgical teams is paramount on the day of the procedure. The operating room should be prepared with the required equipment as indicated by the specific EXIT type. Ideally, the teams are composed of experienced clinicians who work together often and have some continuity. Rehearsal of the procedure with all team members involved is usually performed before the actual procedure. Preparation for massive bleeding and transfusion is critical as the average maternal blood loss during EXIT has been estimated at 1 L.<a class="bibr" href="#article-161554.r29" rid="article-161554.r29">[29]</a></p></div><div id="article-161554.s9"><h2 id="_article-161554_s9_">Technique or Treatment</h2><p>
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<b>EXIT-to-Airway Surgery</b>
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</p><p>The mother is brought into the room and positioned either supine or with a tilt to the left to take pressure off the vena cava. The placental location must be confirmed via ultrasonography before any incisions are made. The abdomen is then prepped and draped in standard fashion for cesarean delivery. A laparotomy is made, and the uterus is exposed. Sterile ultrasound can be used at this point for a final confirmation of hysterotomy location. The hysterotomy is made, and the fetal head, neck, and torso are delivered. Amnioinfusion with warmed lactated ringers is set up to ensure the umbilical cord is not compressed. Although fetal anesthesia is accomplished through the placenta, a small-bore catheter is usually placed, and the fetus is anesthetized further with opioids and muscle relaxants. Fetal vital signs are monitored closely.</p><p>Airway interventions are then started. Initially, intubation via direct laryngoscopy is usually attempted. Adjuncts may include manual distraction of a mass, use of stylets, needle decompression of fluid-filled masses, and partial resections of solid masses. An alternative is upper airway evaluation with a rigid or flexible laryngoscope, followed by the Seldinger technique. Once the airway is identified with the device of choice, a bougie-stylet, flexible laryngoscope, or Hopkins rod can be used to advance the endotracheal tube into position. If anterograde intubation attempts are deemed ineffective, retrograde intubation may be attempted, which involves dissecting the trachea, creating a tracheostomy incision, and feeding a 4- or 8-French nasogastric tube into the mouth. An endotracheal tube is then fixed to the nasogastric tube and pulled into place, and the tracheostomy is closed. However, if closure is impossible, the tracheostomy is formalized. After the airway is secured, other interventions, such as resection of mass or separation of congenital twins, may be pursued.</p><p>Current EXIT procedure protocols create about a 90-minute window for securing the airway.<a class="bibr" href="#article-161554.r5" rid="article-161554.r5">[5]</a><a class="bibr" href="#article-161554.r6" rid="article-161554.r6">[6]</a> Once the airway is secured, the infant is ventilated, and the umbilical cord is clamped. The delivery then proceeds as normal, handing off the infant to the waiting neonatal intensivist team for resuscitation. This step requires direct communication between the anesthesiologist and surgeons, as uterotonics must replace the tocolytics administered during EXIT. Control of maternal hemorrhage is the sole focus of the surgical team at this time. The surgical site is closed, and the mother is transferred to either the intensive care unit or maternal ward for recovery, depending on her status during the case.</p></div><div id="article-161554.s10"><h2 id="_article-161554_s10_">Complications</h2><p>
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<b>Maternal Complications</b>
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</p><p>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.<a class="bibr" href="#article-161554.r6" rid="article-161554.r6">[6]</a><a class="bibr" href="#article-161554.r30" rid="article-161554.r30">[30]</a></p><p>
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<b>Fetal Complications</b>
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</p><p>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.<a class="bibr" href="#article-161554.r31" rid="article-161554.r31">[31]</a> 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.</p></div><div id="article-161554.s11"><h2 id="_article-161554_s11_">Clinical Significance</h2><p>While not common or well-known in the general medical community, the EXIT procedure is lifesaving to most infants needing airway intervention at the time of delivery. Mortality rates of upper airway malformation, head and neck mass, cardiopulmonary malformations, and other specific congenital maladies have drastically declined after the introduction of appropriate prenatal evaluation, team preparation, and meticulous surgical technique. However, EXIT procedures are not without risk to the mother or child, but the possibility of a healthy delivery typically outweighs these risks.<a class="bibr" href="#article-161554.r32" rid="article-161554.r32">[32]</a></p></div><div id="article-161554.s12"><h2 id="_article-161554_s12_">Enhancing Healthcare Team Outcomes </h2><p>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.</p></div><div id="article-161554.s13"><h2 id="_article-161554_s13_">Review Questions</h2><ul><li class="half_rhythm"><div>
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</div></li></ul></div><div id="article-161554.s14"><h2 id="_article-161554_s14_">References</h2><dl class="temp-labeled-list"><dl class="bkr_refwrap"><dt>1.</dt><dd><div class="bk_ref" id="article-161554.r1">Kelly MF, Berenholz L, Rizzo KA, Greco R, Wolfson P, Zwillenberg DA. Approach for oxygenation of the newborn with airway obstruction due to a cervical mass. <span><span class="ref-journal">Ann Otol Rhinol Laryngol. </span>1990 Mar;<span class="ref-vol">99</span>(3 Pt 1):179-82.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/2310132" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 2310132</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>2.</dt><dd><div class="bk_ref" id="article-161554.r2">Suita S, Ikeda K, Nakano H, Ookubo N, Taki I, Ishida T, Tanaka K. Teratoma of the neck in a newborn infant - a case report. <span><span class="ref-journal">Z Kinderchir. </span>1981 Aug;<span class="ref-vol">33</span>(4):355-8.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/7324579" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 7324579</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>3.</dt><dd><div class="bk_ref" id="article-161554.r3">Spiers A, Legendre G, Biquard F, Descamps P, Corroenne R. 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Quantitative estimation of human uterine artery blood flow and pelvic blood flow redistribution in pregnancy. <span><span class="ref-journal">Obstet Gynecol. </span>1992 Dec;<span class="ref-vol">80</span>(6):1000-6.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/1448242" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 1448242</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>11.</dt><dd><div class="bk_ref" id="article-161554.r11">Zia S. Placental location and pregnancy outcome. <span><span class="ref-journal">J Turk Ger Gynecol Assoc. </span>2013;<span class="ref-vol">14</span>(4):190-3.</span> [<a href="/pmc/articles/PMC3935544/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3935544</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24592104" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24592104</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>12.</dt><dd><div class="bk_ref" id="article-161554.r12">David C, Gabrielli S, Pilu G, Bovicelli L. 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A review of historic and recent investigations of the anatomy of the pediatric larynx. <span><span class="ref-journal">Paediatr Anaesth. </span>2018 Jan;<span class="ref-vol">28</span>(1):13-22.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/29148119" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29148119</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>14.</dt><dd><div class="bk_ref" id="article-161554.r14">Wani TM, Rafiq M, Akhter N, AlGhamdi FS, Tobias JD. Upper airway in infants-a computed tomography-based analysis. <span><span class="ref-journal">Paediatr Anaesth. </span>2017 May;<span class="ref-vol">27</span>(5):501-505.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/28256046" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28256046</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>15.</dt><dd><div class="bk_ref" id="article-161554.r15">Wani TM, Rafiq M, Talpur S, Soualmi L, Tobias JD. 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Neonatal Airway Management. <span><span class="ref-journal">Clin Perinatol. </span>2019 Dec;<span class="ref-vol">46</span>(4):745-763.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/31653306" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31653306</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>17.</dt><dd><div class="bk_ref" id="article-161554.r17">Mychaliska GB, Bealer JF, Graf JL, Rosen MA, Adzick NS, Harrison MR. 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Case report: EXIT procedure in cervical teratoma during pregnancy. <span><span class="ref-journal">Acta Otorrinolaringol Esp (Engl Ed). </span>2023 Jan-Feb;<span class="ref-vol">74</span>(1):59-62.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/36708991" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 36708991</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>19.</dt><dd><div class="bk_ref" id="article-161554.r19">Hirose S, Farmer DL, Lee H, Nobuhara KK, Harrison MR. The ex utero intrapartum treatment procedure: Looking back at the EXIT. <span><span class="ref-journal">J Pediatr Surg. </span>2004 Mar;<span class="ref-vol">39</span>(3):375-80; discussion 375-80.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/15017555" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15017555</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>20.</dt><dd><div class="bk_ref" id="article-161554.r20">Michel TC, Rosenberg AL, Polley LS. EXIT to ECMO. <span><span class="ref-journal">Anesthesiology. </span>2002 Jul;<span class="ref-vol">97</span>(1):267-8.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/12131131" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12131131</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>21.</dt><dd><div class="bk_ref" id="article-161554.r21">Ossowski K, Suskind DL. Airway management in conjoined twins: a rare indication for the EXIT procedure. <span><span class="ref-journal">Arch Otolaryngol Head Neck Surg. </span>2005 Jan;<span class="ref-vol">131</span>(1):58-60.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/15655187" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15655187</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>22.</dt><dd><div class="bk_ref" id="article-161554.r22">Mohammad S, Olutoye OA. Airway management for neonates requiring ex utero intrapartum treatment (EXIT). <span><span class="ref-journal">Paediatr Anaesth. </span>2020 Mar;<span class="ref-vol">30</span>(3):248-256.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/31898837" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31898837</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>23.</dt><dd><div class="bk_ref" id="article-161554.r23">Lazar DA, Cassady CI, Olutoye OO, Moise KJ, Johnson A, Lee TC, Cass DL. Tracheoesophageal displacement index and predictors of airway obstruction for fetuses with neck masses. <span><span class="ref-journal">J Pediatr Surg. </span>2012 Jan;<span class="ref-vol">47</span>(1):46-50.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/22244391" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22244391</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>24.</dt><dd><div class="bk_ref" id="article-161554.r24">Prickett K, Javia L. Fetal Evaluation and Airway Management. <span><span class="ref-journal">Clin Perinatol. </span>2018 Dec;<span class="ref-vol">45</span>(4):609-628.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/30396408" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30396408</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>25.</dt><dd><div class="bk_ref" id="article-161554.r25">Merz E, Pashaj S. Advantages of 3D ultrasound in the assessment of fetal abnormalities. <span><span class="ref-journal">J Perinat Med. </span>2017 Aug 28;<span class="ref-vol">45</span>(6):643-650.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/28157693" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28157693</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>26.</dt><dd><div class="bk_ref" id="article-161554.r26">Manganaro L, Antonelli A, Bernardo S, Capozza F, Petrillo R, Satta S, Vinci V, Saldari M, Maccioni F, Ballesio L, Catalano C. Highlights on MRI of the fetal body. <span><span class="ref-journal">Radiol Med. </span>2018 Apr;<span class="ref-vol">123</span>(4):271-285.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/29164364" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29164364</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>27.</dt><dd><div class="bk_ref" id="article-161554.r27">Cruz-Martinez R, Moreno-Alvarez O, Garcia M, Méndez A, Pineda H, Cruz-Martinez MA, Martinez-Morales C. Fetal Endoscopic Tracheal Intubation: A New Fetoscopic Procedure to Ensure Extrauterine Tracheal Permeability in a Case with Congenital Cervical Teratoma. <span><span class="ref-journal">Fetal Diagn Ther. </span>2015;<span class="ref-vol">38</span>(2):154-8.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/25228387" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25228387</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>28.</dt><dd><div class="bk_ref" id="article-161554.r28">Mosquera MS, Yuter S, Flake AW. Perinatal management of the anticipated difficult airway. <span><span class="ref-journal">Semin Fetal Neonatal Med. </span>2023 Oct;<span class="ref-vol">28</span>(5):101485.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/38030438" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 38030438</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>29.</dt><dd><div class="bk_ref" id="article-161554.r29">Butwick A, Aleshi P, Yamout I. Obstetric hemorrhage during an EXIT procedure for severe fetal airway obstruction. <span><span class="ref-journal">Can J Anaesth. </span>2009 Jun;<span class="ref-vol">56</span>(6):437-42.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/19396506" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19396506</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>30.</dt><dd><div class="bk_ref" id="article-161554.r30">Zamora IJ, Ethun CG, Evans LM, Olutoye OO, Ivey RT, Haeri S, Belfort MA, Lee TC, Cass DL. Maternal morbidity and reproductive outcomes related to fetal surgery. <span><span class="ref-journal">J Pediatr Surg. </span>2013 May;<span class="ref-vol">48</span>(5):951-5.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/23701766" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23701766</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>31.</dt><dd><div class="bk_ref" id="article-161554.r31">Dick JR, Wimalasundera R, Nandi R. Maternal and fetal anaesthesia for fetal surgery. <span><span class="ref-journal">Anaesthesia. </span>2021 Apr;<span class="ref-vol">76 Suppl 4</span>:63-68.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/33682103" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 33682103</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>32.</dt><dd><div class="bk_ref" id="article-161554.r32">Lazar DA, Olutoye OO, Moise KJ, Ivey RT, Johnson A, Ayres N, Olutoye OA, Rodriguez MA, Cass DL. Ex-utero intrapartum treatment procedure for giant neck masses--fetal and maternal outcomes. <span><span class="ref-journal">J Pediatr Surg. </span>2011 May;<span class="ref-vol">46</span>(5):817-22.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/21616233" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21616233</span></a>]</div></dd></dl></dl></div><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Russell De Jong declares no relevant financial relationships with ineligible companies.</p></div></dd></dl><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Taylor Fordham declares no relevant financial relationships with ineligible companies.</p></div></dd></dl></dl></div></div></div><div class="fm-sec"><h2 id="_NBK604209_pubdet_">Publication Details</h2><h3>Author Information and Affiliations</h3><p class="contrib-group"><h4>Authors</h4><span itemprop="author">Russell De Jong</span><sup>1</sup>; <span itemprop="author">Taylor Fordham</span><sup>2</sup>.</p><h4>Affiliations</h4><div class="affiliation"><sup>1</sup> Brooke Army Medical Center, San Antonio, TX</div><div class="affiliation"><sup>2</sup> Christus Children's - Baylor College of Medicine</div><h3>Publication History</h3><p class="small">Last Update: <span itemprop="dateModified">May 25, 2024</span>.</p><h3>Copyright</h3><div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © 2025, StatPearls Publishing LLC.<p class="small">
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This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)
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(<a href="https://creativecommons.org/licenses/by-nc-nd/4.0/" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=uri">
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http://creativecommons.org/licenses/by-nc-nd/4.0/
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</a>), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.
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</p></div></div><h3>Publisher</h3><p><a href="https://www.statpearls.com/" ref="pagearea=page-banner&targetsite=external&targetcat=link&targettype=publisher">StatPearls Publishing</a>, Treasure Island (FL)</p><h3>NLM Citation</h3><p>De Jong R, Fordham T. Ex utero Intrapartum Treatment (EXIT) Procedure. [Updated 2024 May 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. <span class="bk_cite_avail"></span></p></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
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