The EXIT (Ex Utero Intrapartum Treatment) Procedure

Fetuses with upper airway obstruction have a high mortality rate if proper airway management is not immediately administered after delivery. The EXIT (ex utero intrapartum treatment) procedure is a new technique that establishes the fetal airway while uteroplacental circulation is still maintained. The prognosis of such neonates has much improved after the introduction of this procedure. We report two neonates with prenatal diagnosis of upper airway obstruction; they were born smoothly via the EXIT procedure. The first was a case of epignathus, a rare type of nasopharyngeal or oropharyngeal teratoma derived from all three germ cell layers with variable maturity. The second was a case of giant lymphangioma that resulted from localized malformations in the development of the lymphatic system. Furthermore, compared with routine cesarean section, the short-term maternal outcomes were not different with regard to infection rate, estimated blood loss, wound complication, and postpartum hospital stay.     

The EX-utero Intrapartum Technique (EXIT) procedure in Italy

Aim of the study was to present the first two Italian cases of C-section performed with the EXIT procedure (EX-utero Intrapartum Technique). Deliveries were performed at the Division of Obstetrics and Gynecology of the Hospital of Padua in cooperation with the Pediatric Surgery Department, both tertiary care centers. The first case was a twin with a huge neck mass (cystic hygroma) and the second a fetus with an oropharyngeal mass (epignathus). Airway patency could have been compromised at birth in both of them. EXIT procedure consists in securing the airway of the fetus partially delivered and still connected with the placenta. This technique leaves an intact feto-placental circulation and guarantees a normal fetal oxygenation while fetal airway patency is secured. Both the fetuses were successfully intubated and the C-section ended up in a short period of time without maternal and fetal complications. The EXIT technique, performed for the first time in 1989 and now in many centers abroad, can be considered a safe procedure as long as a multidisciplinary approach is carried out. The EXIT procedure is indicated whenever fetal airways can be compromised at birth, that is when oropharyngeal masses, laryngeal atresia, cystic hygroma and goiter are encountered during prenatal ultrasound.     

Intrapartum Fetal Monitoring: One Year's Experience at a Canadian Teaching Hospital

A report of activities in the fetal monitoring unit of a university teaching hospital for the year 1974 is presented. It is shown that significant steps toward optimal reduction of perinatal morbidity and mortality were taken.     

Women's Evaluations of Their Experience in a Multicenter Randomized Controlled Trial of Intrapartum Fetal Pulse Oximetry (The FOREMOST Trial)

Abstract: Background: Fetal pulse oximetry improves the assessment of fetal well‐being during labor. The objective of this study was to evaluate women's satisfaction with their experience with this additional technology. Methods: We surveyed women participating in the FOREMOST trial, a randomized controlled trial comparing the addition of fetal pulse oximetry (FPO) to conventional cardiotocograph (CTG) monitoring (intervention group), versus CTG‐only (control group), in the presence of nonreassuring fetal status during labor. Our survey evaluated 3 aspects of women's experience: labor, fetal monitoring, and participation in the research. The survey was administered within a few days of giving birth and repeated 3 months later. Results: No differences were found between the intervention and control groups for women's evaluations of their labor, fetal monitoring, research, or overall experiences when surveyed on both occasions. Within each study group, a small but statistically significant decline occurred in women's scores for their experience of labor and overall experience from the initial survey close to the time of giving birth, to 3 months later. The magnitude of differences in responses over time was similar for the both groups. Women were more satisfied after a spontaneous or assisted vaginal birth than after cesarean section. Length of time the research midwife was present had a significant positive effect on women's ratings of their experience several days after giving birth (p = 0.006), but no effect at 3 months. Conclusions: The addition of fetal pulse oximetry for the assessment of fetal well‐being during labor did not affect childbearing women's perceptions of fetal monitoring or their labor. Women evaluated their experience in the research process positively overall. Small changes occurred in women's perception of their satisfaction over time. (BIRTH 33:2 June 2006)     

Intermittent Auscultation for the Intrapartum Assessment of Fetal Well-being in Western Australia

Summary: In May 1995, in response to a decision of die Perinatal and Infant Mortality Committee of Western Australia, a survey of Western Australian hospitals was performed to ascertain what policies were in use for the monitoring of the fetal heart rate in labour and what proportion of these hospitals had access to electronic monitoring by cardiotocography. A response was received from 96% of the surveyed hospitals. More than half the births in this State (13,950 of 25,238) were monitored in labour using intermittent auscultation as the primary test; 7.5% of Western Australian births each year occurred in hospitals in which electronic monitoring was not available. Fewer than 50% of hospitals had written protocols describing the method of auscultation of the fetal heart during labour, the indications to contact a doctor or the management of fetal distress. The protocols which did exist displayed considerable variation in the recommended frequency of intermittent auscultation. The lack of standard practice in this field probably results from uncertainties in the literature. Intermittent auscultation has not been subjected to rigorous scientific evaluation as a screening tool and guidelines documenting ideal auscultatory practices need to balance the precision of electronic monitoring and freedom from intervention. Based on this compromise and existing evidence, a protocol for intermittent auscultation in normal labour is proposed.     

脐血流测定对脐带绕颈的产时监护

目的 :研究脐血流测定对脐带绕颈的产时监护作用。方法 :对 5 5 0例单胎足月妊娠孕妇进行脐血流测定 ,其中脐带绕颈 138例。分A、B、C 3组 ,分析其产时胎儿宫内窘迫发生率 (简称 :胎窘率 )及剖宫产率 ,并动态观察 14 0例(其中脐带绕颈 5 2例 ,无绕颈 88例 )产妇 ,产程中的脐血流变化。结果 :3组脐带长度、绕颈周数、新生儿Apgar评分 ,差异无显著性 (P >0 0 5 )。B组与C组的产时胎窘率及剖宫产率均较A组高 (P <0 0 1,P <0 0 5 )。产程中 ,S/D升高 >0 1,有脐带绕颈组明显高于无绕颈组 (P <0 0 1) ,S/D >3 0与 2 70 相似文献   

ST Waveform Analysis versus Cardiotocography Alone for Intrapartum Fetal Monitoring: A Meta-Analysis of Randomized Trials

Objective To estimate the effectiveness of intrapartum ST waveform analysis (STAN) versus cardiotocography (CTG) alone in prevention of metabolic acidosis.Study Design Meta-analysis of randomized trials comparing intrapartum fetal monitoring utilizing STAN with CTG versus CTG alone. Primary outcome was neonatal metabolic acidosis, defined as umbilical arterial pH <7.05 and base deficit >12 mmol/L.Results Five randomized trials including 15,303 singletons, vertex, term, or near-term pregnancies met inclusion criteria and were analyzed. Compared with CTG alone, STAN with CTG was associated with similar incidences of metabolic acidosis (0.81% versus 1.12%, relative risk [RR] 0.80; 95% confidence interval [CI] 0.44 to 1.47), perinatal death, neonatal encephalopathy, Apgar score <7 at 5 minutes, admission to neonatal intensive care unit, and cesarean delivery. Operative vaginal delivery (OVD) was lower in the STAN with CTG compared with CTG alone (13.56% versus 15.20%; RR 0.89; 95% CI 0.83 to 0.97).Conclusion There is no difference in perinatal outcomes between STAN with CTG compared with CTG alone, except for lower rate of OVD.     

Intermittent Auscultation for Intrapartum Fetal Heart Rate Surveillance: American College of Nurse‐Midwives

Fetal heart rate surveillance is a standard component of intrapartum care. The fetal heart rate can be evaluated using intermittent auscultation or electronic fetal monitoring. Research that has compared these 2 strategies found them to be equivalent with respect to long‐term neonatal outcomes. The purpose of this clinical bulletin by the American College of Nurse‐Midwives is to review the evidence for use of intermittent auscultation and provide recommendations for intermittent auscultation technique, interpretation, and documentation.     

The Fetal Safety of Hydrocortisone-Pramoxine (Proctofoam-HC) for the Treatment of Hemorrhoids in Late Pregnancy

ObjectiveFetal safety has never been studied for any drug used in the treatment of hemorrhoids. Proctofoam-HC is a combination of a corticosteroid and a local anaesthetic that is proven effective for the treatment of hemorrhoids. The objective of this study was to assess prospectively the fetal safety of third trimester exposure to Proctofoam-HC.MethodsIn a multicentre study, 240 women exposed to Proctofoam-HC in the third trimester and a similar number of control pregnant women were followed up postnatally.ResultsWhen compared to controls exposure to Proctofoam-HC was not associated with any adverse fetal effects on birth weight, gestational age, rates of prematurity, or pre- or postnatal complications.ConclusionProctofoam-HC is safe to use in the treatment of hemorrhoids in late pregnancy.     

Group B Streptococcus (GBS) and Neonatal Infections: The Case for Intrapartum Chemoprophylaxis

At the Royal Women's Hospital, Melbourne over an 8-year period (1981-1988) all public antenatal patients were screened at 32 weeks' gestation for group B streptococcus (GBS). In a total of 30,197 livebirths there were no early onset neonatal GBS infections in infants of treated asymptomatic carrier mothers. By contrast there were 27 infections with 8 deaths in an unscreened control group of private patients (total livebirths 26,915). It is recommended that GBS screening occur antenatally at 28 weeks and that intrapartum chemoprophylaxis be offered at least to those carriers with obstetric risk factors.     

The ex utero intrapartum treatment (EXIT) procedure in giant fetal neck masses

Giant fetal neck masses can cause airway obstructions with potential poor fetal prognosis after delivery. The relationship between the fetal neck mass and airway structure can be defined prenatally with ultrasound and magnetic resonance imaging (MRI). The ex utero intrapartum treatment (EXIT) procedure is an available technique to obtain a fetal airway while feto-maternal circulation is preserved. We present a case in which prenatally a giant fetal neck mass was diagnosed on ultrasound and MRI, and a successful EXIT procedure could be performed.     

Maternal Hyperoxygenation for the Treatment of Fetal Growth Retardation

Maternal hyperoxygenation has been demonstrated to improve fetal pO₂, and was suggested as a treatment for intrauterine growth retardation. Our initial results with such treatment are presented. Four patients with fetal growth retardation were continuously treated with oxygen enriched air breathed through a face mask. Growth retardation was determined by sonographic estimates of low weight, increased head to abdominal circumference ratio, oligohydramnios, and abnormal resistance to flow in the umbilical artery. In all cases prolongation of pregnancy has become possible, doppler flow parameters have improved, and the immediate perinatal outcome was good. Additional clinical experience, with maternal hyperoxygenation, is needed before its usefulness in the treatment of intrauterine growth retardation can be determined.