Ex-utero intrapartum treatment (EXIT) and immediate postpartum access to cardiac therapies (IMPACT) deliveries

What are EXIT and IMPACT deliveries?

Sometimes babies with certain health conditions require a special, planned delivery method so that they can immediately get the medical attention they need and make a more stable transition to life outside the womb. 

The ex utero intrapartum treatment (EXIT) procedure is used with babies whose airways are obstructed by tumors or other fetal anomalies, such as congenital diaphragmatic hernia or congenital pulmonary airway malformation. It involves partially delivering the baby and keeping him or her attached to the placenta during the surgical repair, with the umbilical cord and placenta acting as life support. This complex procedure is available at only the most specialized centers, and the Fetal Concerns Center at Children’s Wisconsin was proud to perform the state’s first EXIT delivery in 2010.

During the procedure, the mother and baby are asleep under general anesthesia, which keeps the placenta relaxed and prevents detachment. Mother and baby are also given medications for pain control. The operating room team includes multidisciplinary experts dedicated to caring for mom and baby: maternal fetal medicine specialists, a fetal surgeon, a fetal cardiologist who monitors the baby’s heartbeats, and anesthesiologists for both the baby and mother.

After making the incision in the mother using a special device to minimize uterine bleeding, the surgeon partially delivers the baby’s head and shoulders through the opening, keeping the baby attached to the placenta so he or she can continue to receive vital oxygen and nutrients from the mother. The medical team infuses warm fluids into the uterus to keep amniotic fluid levels normal, allowing the fetus and umbilical cord to continue to float and remain safe. The baby is attached to monitors and IVs, and then the surgeon works on the baby. After the baby’s procedure is complete and his or her condition is stable, the umbilical cord is cut. The surgeon then closes the mom’s uterus and abdominal incision. Mother and baby are also given antibiotics to prevent infection. The entire procedure takes approximately two hours.

An immediate postpartum access to cardiac therapies (IMPACT) delivery is used when a baby with severe heart defects (such as hypoplastic, with other complicating factors) faces life-threatening cardiovascular or respiratory problems as soon as he or she is disconnected from the placenta. In those cases, the baby is delivered via C-section in a cardiac operating room and then sent to an adjacent room for immediate cardiac catheterization or heart surgery. The experts in Children’s Wisconsin's Fetal Concerns Center and Herma Heart Institute have been collaborating on IMPACT deliveries since 2012.

Candidates for EXIT and IMPACT deliveries

The need for an EXIT or IMPACT delivery is usually discovered during a prenatal ultrasound. Not every baby is a candidate for these types of deliveries. For safety’s sake, patients must meet the following criteria:
• There must be a compelling reason for an EXIT or IMPACT procedure, such as a defect that could lead to life-threatening complications as soon as the baby detaches from the placenta.
• The surgery should be done once the pregnancy is near term — generally by 37 weeks — unless the baby’s condition worsens and requires earlier intervention.

The specialists at the Fetal Concerns Center will help you decide whether an EXIT or IMPACT procedure is the right option for you and your baby.

How does an EXIT or IMPACT delivery affect my baby?

These delivery methods help avoid a crisis situation and have been shown to improve outcomes in situations that might otherwise be fatal. In some cases, babies might require additional breathing support after birth in the form of a breathing tube or extracorporeal membrane oxygenation (ECMO), which is a machine that functions as the baby’s lungs. Depending on your baby’s diagnosis, he or she might also require additional surgery after birth to treat the underlying problem.

How does EXIT or IMPACT delivery affect the pregnancy?

To decrease the risk of preterm delivery before a planned EXIT or IMPACT procedure, you will need to deliver your baby via a scheduled C-section around 37 weeks, unless you go into labor earlier, at the Froedtert & the Medical College of Wisconsin Birth Center.

What about after surgery?

You will remain in the hospital for 3-4 days after an EXIT or IMPACT delivery, similar to a traditional C-section. After your baby is born, he or she will receive top-notch care in Children’s Wisconsin’s Level IV Neonatal Intensive Care Unit, which is ranked as one of the best in the nation, or the Cardiac Intensive Care Unit.

Will I be able to help care for my baby?

Absolutely. Our recently expanded and redesigned NICU was created to promote family bonding, with private rooms where parents can stay with their baby 24/7, and other special features for families’ comfort. Our on-call lactation specialists can help you successfully breastfeed and pump and store breast milk when direct breastfeeding isn’t an option.

When can my baby go home?

Your baby will be discharged from the hospital once he or she is breathing independently, eating well and gaining weight. That may take several weeks. Premature babies will likely require a longer NICU stay.

What’s my baby’s long-term prognosis?