Development of a Fetal Surgery Program to Improve Neonatal Outcomes

Abstract

In 2017, our pediatric hospital developed a fetal surgery program offering in utero procedures to repair complex congenital anomalies. The service provides comprehensive care for the maternal-fetal dyad, in one location. Fetal surgery allows for treatment of specific fetal conditions that were once considered life threatening or only treatable after birth. Emerging evidence demonstrates that treatment of certain fetal conditions increases a baby’s chances of survival and improved health. Leadership and frontline staff collaborated with specialists and surgeons to develop guidelines and protocols in the implementation of this program. Our hospital was one of the first pediatric facilities in the United States to offer inpatient obstetric care for women who experience complex fetal diagnoses. An interprofessional response to fetal complications was well established within the center. The provision of fetal surgery options was a continuance of the center’s approach of comprehensive care for the maternal-fetal dyad. Extensive program development included the following: addition of a fetal surgeon; creation of nurse coordinator roles to provide support, education, and comprehensive follow-up care for patients; exhaustive literature reviews; development of process flow diagrams to delineate roles and responsibilities; and didactic and operative skills training for staff, including simulations, mandatory preprocedure huddles, and formalized procedure debriefing. Our team has now successfully performed more than 90 fetal surgeries, such as open fetal myelomeningocele (fMMC) repair, open fetal teratoma resection, fetoscopic laser treatment for twin-to-twin complications, and complex ex utero intrapartum treatment procedures. The center has completed 14 open fMMC repairs, with early outcomes data demonstrating a 15% postbirth shunt placement rate. These are encouraging data compared with the MOMS trial, which indicated a 40% shunt placement rate in those with prenatal repair and an 82% shunt placement rate with postnatal repair. For our center, the average gestational age at the time of repair was 25.4 weeks and the average gestational age at birth was 35.2 weeks. Program development challenges included logistics planning, resource allocation, and staff trepidation. Challenges were overcome through teamwork, research, and an unflagging focus on evidence-based, best-practice models. Inclusion of frontline nursing staff was critical to the success of this innovative program.