Inside the mother’s womb, a fetus exchanges oxygen through the umbilical cord. Once the fetus is delivered, the umbilical cord is clamped, giving the baby the ability to breathe oxygen independently. In rare cases, the fetus has a severe congenital abnormality that obstructs the airway and makes independent breathing after delivery difficult or impossible. Instead of a traditional birth, an innovative surgical procedure, the Ex Utero Intrapartum Treatment (EXIT), is performed to deliver the baby. During this procedure, the baby’s head and shoulders are delivered by an elective Cesarean section, leaving the umbilical cord and placenta intact while pediatricians establish an independent, free airway. After the airway is well established by the pediatricians, the umbilical cord is clamped, and the baby is delivered completely. The procedure may take up to five to ten minutes and requires full coordination between obstetrics, anesthesia, and pediatric teams. USF Health and Tampa General Hospital’s multidisciplinary team performed its first EXIT procedure in 2009 and second in 2016. January 2019 marked the third time in order to deliver a baby with a growth from the tongue that was compressing the airway.

The January 2019 EXIT delivery team featured Sarah Obican, MD, high-risk obstetrician, maternal-fetal medicine subspecialist, who performed the surgery and delivery of the baby in order for the airway to be established. (Photo courtesy of the USF Health Fetal Care Center of Tampa Bay)

“When you do cases of such complexity, you can’t do it alone. You need to have an institution that offers all these subspecialists in one setting and that’s what USF offers,” said Prasad Burjonrappa, MD, MBA, division chief of Pediatric Surgery. Dr. Burjonrappa’s role during the 2019 EXIT procedure was to work alongside Jaime Flores-Torres, MD, neonatologist, to evaluate the infant’s airway and determine if he was a candidate for endotracheal intubation, the placement of a tube into the trachea through the mouth or nose, or if the baby needed a tracheostomy, a surgical procedure to create an opening through the neck into the trachea.

(Left) The baby was born with a growth from the tongue that was compressing his airway. (Right) After the removal of the mass, the baby went home a few days later with no complications. (Photos courtesy of the USF Health Fetal Care Center of Tampa Bay)

An EXIT procedure involves two patients – mother and baby – who each need specialized care to avoid complications. This is why the procedure requires a multidisciplinary team of up to 20 physicians and other health practitioners. With such a large team working together, the procedure needs to be highly coordinated because it’s critical that everyone knows their role, when to act, and how long they have to finish. The USF-TGH team establishes protocols and contingency plans and practices mock surgeries to prepare for every outcome. To ensure the procedure runs smoothly, Anthony Odibo, MD, MSCE, FRCOG, FACOG, director of the USF Health Fetal Care Center of Tampa Bay, oversees and directs the various teams that come together to make the high-risk delivery a success.

“The most challenging part of this is the unknown,” said Sara Zientara, fetal care coordinator for the Fetal Care Center. “You don’t know exactly how that baby is going to come out. You don’t know exactly how that surgery is going to go and you just have to take it as it comes and be able to multitask and problem solve, so preparing everyone for what their role is and could be is important.”

Thanks to the well-established USF Health Fetal Care Center at Tampa General Hospital and the prepared and coordinated team, the January 2019 delivery was yet another success. Once the baby was born and was transferred to an ICU, the baby stayed intubated until the procedure to remove the mass was complete, and then the mother and baby went home a couple of days later without any major complications.

A small part of the EXIT procedure team at the USF Health Fetal Care Center of Tampa Bay located at Tampa General Hospital. (From left to right) Amy Amato, clinician of operations for the TGH women’s operating room, Jaime Flores-Torres, MD, neonatologist, Prasad Burjonrappa, MD, MBA, division chief of Pediatric Surgery, Sarah Obican, MD, high-risk obstetrician, maternal-fetal medicine subspecialist, Sara Zientara, coordinator for the Fetal Care Center, Chinedu Nwabuobi, MD, MS, 3rd-year maternal-fetal medicine fellow. (Photo by Allison Long)

Learn more about the USF Health Fetal Care Center’s multidisciplinary team involved in this EXIT procedure.

Story by Torie Doll. Videos by Torie Doll and Allison Long.