UNC Health Talk

Doctors at UNC Hospitals perform rare, complex surgery to save life of newborn

June 11, 2003

Doctors at UNC Hospitals perform rare, complex surgery to save life of newborn

CHAPEL HILL, N.C. – Physicians at UNC Hospitals on Monday performed a rare, complex operation on an infant whose head and shoulders were delivered by Caesarean section while the rest of the baby stayed inside the mother’s womb.

This was the first time the procedure – called an “ex utero intrapartum treatment” or “EXIT” procedure – had been performed at UNC Hospitals.

Dr. Nancy Chescheir led a surgical team that first delivered the head and shoulders of the baby, and then placed a tube through the nose into the trachea to establish an airway for the baby. The life-saving surgery was needed because without the EXIT procedure, the infant faced the risk of suffocating to death once the umbilical cord was cut.

Once the airway was established, delivery was completed and the umbilical cord cut. Then doctors performed a tracheostomy – an opening surgically created through the neck into the trachea – to maintain the baby’s airway. The baby is now being cared for in the Newborn Critical Care Center in the N.C. Children’s Hospital, where it is doing well. Meanwhile, the mother is resting comfortably nearby in the N.C. Women’s Hospital, which is adjacent to the Children’s Hospital.

“Performing the first EXIT procedure at UNC Hospitals is a huge step forward,” said Dr. Valerie Parisi, chair of the Department of Obstetrics and Gynecology. “Dr. Chescheir’s expertise and her role as the fetal surgery officer at the National Institutes of Health have helped us to achieve this goal. The women and children of North Carolina are very fortunate that this procedure is available to them in their home state.”

Dr. Alan Stiles, chair of the Department of Pediatrics, added that the EXIT procedure “has opened new doorways for UNC Hospitals to provide treatment for complex congenital anomalies that are available at only a few places nationally.”

Ultrasound images showed that the baby had structural defects that were likely to leave it unable to breathe on its own. One was bilateral facial clefting, meaning the baby essentially had a mouth that went from ear to ear and lacked several important facial muscles. In addition, the infant has a cleft palate and micrognathia, a condition marked in this baby’s case by a severely receding chin. Facial reconstructive surgery will be needed later to correct these problems.

As long as the infant remained attached to its mother’s placenta, it received enough oxygen to sustain life. The multidisciplinary team evaluating the fetus by ultrasound prior to birth predicted that it would be extremely difficult to establish a secure airway for the baby quickly after a routine birth. Once the umbilical cord is cut, a newborn must be able to breathe on its own quickly or could suffer brain damage or even death.

The operation involved a team of 11 physicians. Dr. Nancy Chescheir and Dr. Amy Adelberg are high-risk obstetricians, from the Department of Obstetrics and Gynecology. Dr. David Mayer and Dr. Robert Valley are anesthesiologists, specializing in anesthesia for pregnant women and children, respectively. The pediatric team included two neonatologists, Dr. Kate Veness-Meehan and Dr. Mario Rojas. Two members of the Department of Surgery in the division of pediatric surgery also participated,  Dr. Duncan Phillips and Dr. Tim Weiner, and a member of the Department of Otolaryngology, Dr. Carlton Zdanski, was also present. Dr. George Retsch-Bogart, a pediatric pulmanologist, rounded out the treatment team. In addition, nurses from all of the disciplines also participated.

The EXIT procedure was developed at the University of California at San Francisco in 1993. It remains a relatively rare procedure that, because of its great complexity, is usually performed at facilities like UNC Hospitals – a teaching hospital affiliated with one of the nation’s top medical schools.

UNC Hospitals in May 2001 established a fetal therapy and surgery protocol for the EXIT procedure and began evaluating pregnant women whose babies might need it. By offering this procedure, UNC Hospitals is maintaining a cutting-edge response to delivery of care for high-risk children with upper airway obstruction.

The services provided for the mother and baby who had the EXIT surgery on Monday were coordinated by the UNC Center for Maternal and Infant Health, a collaborative initiative of the UNC School of Medicine’s departments of Obstetrics and Gynecology and Pediatrics, and UNC Health Care’s North Carolina Women’s and Children’s hospitals. The center is dedicated to improving the health of all women and infants in the state through clinical services, outreach programs, education and research.

In caring for its patients, the center assembles a wide range of medical expertise in one location and then carefully directs the delivery of treatment to ensure the best care possible. By offering coordinated services for pregnant women and their infants with serious medical conditions, the center provides diagnosis, consultation and expert care to avoid or lessen the severity of birth complications. The first center of its kind in the country, the UNC Center for Maternal and Infant Health is creating a model system of perinatal care.

Note:  Two photos taken during the EXIT procedure performed Monday at UNC Hospitals are available for downloading at .

Media contact: Tom Hughes, (919) 966-6047, tahughes@unch.unc.edu