Elianna Rodriguez was born May 25, but first doctors had to make sure she would be able to breathe on her own.
Elianna had a mass in her neck that was compressing her airway. Doctors at Yale New Haven Children’s Hospital’s Fetal Care Center decided the best way to treat her was to partially deliver her at just under 35 weeks, insert a breathing tube in her trachea and then deliver her.
During the procedure, Elianna’s head and shoulders were outside the uterus, while the womb was kept in a relaxed state so contractions would not begin. It’s known as ex utero intrapartum treatment, or EXIT, and it ensures the baby is kept in an environment as close to the womb as possible.
“The head is outside the body, so the uterus and the baby needs to be kept warm and controlled,” said Dr. Mert Ozan Bahtiyar, co-director of the Fetal Care Center, who performed the procedure.
Courtesy of Summer Rodriguez
Ruben and Summer Rodriguez with their children, Jayson, 3, and Elianna, 2 months.
“The cord is still attached. We need to make sure that the cord is not compressed because, once the uterus is open, the amniotic fluid leaks out,” he said. “The baby needs to still be kept warm, like in-utero environments in operating rooms.”
The mass, a benign teratoma, was removed two weeks later. Elianna now is a healthy baby girl.
“I started to have a feeling that something was wrong around 26 weeks,” said Elianna’s mother, Summer Rodriguez, 22, of Naugatuck. “I was measuring bigger … At 32 weeks I had extra fluid in my belly.”
That was because Elianna wasn’t able to swallow the amniotic fluid surrounding her, so it built up in Rodriguez’s uterus, a condition called polyhydramnios.
Rodriguez said that, when she and her husband, Ruben Rodriguez, heard their daughter would need the EXIT procedure, “It was scary, and it was very overwhelming. We were not prepared to hear something like that because, prior to that … she was healthy. So we were definitely not prepared to hear that information.”
Courtesy Summer Rodriguez
Elianna Rodriguez, with her mother, Summer Rodriguez, underwent a partial birth procedure known as EXIT because of a mass in her neck.
Summer Rodriguez also was disappointed that she would not be awake during Elianna’s delivery, especially since she had had to be anesthetized during her son Jayson’s birth as well.
“I cried for a very long time,” she said. “I felt like I was hit by a train when I heard the way that she had to be delivered, because my first son was delivered also via emergency C-section, and I was put to sleep with him. So the one thing I didn’t want was to be put to sleep.”
However, Bahtiyar reassured her that the procedure would go well.
Yale University
Dr. Mert Ozan Bahtiyar, co-director of Yale New Haven Children’s Hospital’s Fetal Care Center
“Everything that he did just made everything a little bit less scary,” Rodriguez said. “It was always scary, but he was so prepared and so confident and so caring. He wasn’t just talking like a doctor. He was making sure that I knew that he cared and that he knew exactly how I felt and was very considerate of the way that I was feeling.”
Elianna was scheduled to be born June 9, but the procedure had to be moved up to May 25. Rodriguez said 2 liters of amniotic fluid were removed from her uterus. “There are times that we have to reduce the fluid just to temporarily relax the uterus so that the mother doesn’t go into preterm labor,” Bahtiyar said.
“The majority of amniotic fluid is the baby’s urine,” he said. “And that is circulated by swallowing the amniotic fluid and it continues to be a constant circulation. If the fetus cannot swallow, the amniotic fluid will continue to be produced. Eventually what happens is that there would be too much amniotic fluid around the baby, which in turn leads to some contractions, which happened to this patient as well.”
Elianna was fine while she was in utero, but that would have changed once she was delivered without the EXIT procedure, according to Dr. David Stitelman, surgical director of the Fetal Care Center.
Ya;le University
Dr. David Stitelman, surgical director of Yale New Haven Children’s Hospital’s Fetal Care Center
“With a neck mass … the concern is that when the baby goes to take their first breath, they’re going to be in trouble,” he said. “They’re fine when they’re hooked up to the umbilical cord. They’re getting all the nutrients and all the carbon dioxide exchanged through the umbilical cord at the present. But the concern is, when that baby goes to take a first breath, their airway is occluded.”
EXIT is similar to a caesarian section, but has key differences, Stitelman said. The uterus must be kept in a relaxed state. During a C-section, it is likely contracting.
During the procedure, the baby’s head and shoulders are outside the uterus. “We just need to really determine the extent of the lesion,” Bahtiyar said. “We have ultrasound, good high-resolution MRI and everything.”
However, in examining the baby’s neck directly, “the information that we can get is very different. It’s just more precise for planning,” he said.
Yale New Haven Hospital
A large medical team was needed to perform the EXIT procedure on Summer Rodriguez and her daughter Elianna on May 25, 2023.
“The mom gets a very deep anesthesia that relaxes the uterus,” Bahtiyar said. “Once the uterus is open, the placenta does not try to separate itself due to contraction. That allows the placenta to be attached to the mother up to 30 to 45 minutes or so. This is our window.”
The doctors must intubate the baby within that window to avoid brain damage, he said.
The procedure, which was preceded by several simulations, required a large team, Stitelman said.
“That’s a coordinated effort with OB (obstetrics), anesthesiology to monitor the mother, pediatric anesthesiology and maternal fetal medicine to monitor and support the fetus … and surgery to help open up the uterus,” he said. Ear, nose and throat specialists then insert a breathing tube.
“Not every place that has OB can do this,” Bahtiyar said. “It really requires dedication from multiple people.”
The breathing tube stayed in two weeks, until Dr. Kiley Trott, an ear, nose and throat surgeon, removed the mass. A teratoma is “a solid tumor,” Stitelman said. “It’s the type of tumor that can become any tissue in the body. So they often have teeth and hair and fat inside of them.”
Rodriguez said registered nurse Diana Giasullo, fetal therapy nurse coordinator, “was always there to make sure that I was OK emotionally and mentally and just being there as a person to vent to and tell her about how I was feeling and if I had any questions or concerns … I was always able to reach out to her.”
She praised all the nurses and doctors. “They actually care for Eliana and when she comes into the office, they treat her as family.”
Ed Stannard can be reached at [email protected].
