 Hi, I am Dr. Gayathri Karthik, consultant obstetrics and gynecology at Manipal Hospital. I was referred this patient with a difficult, with a large tumor in the baby causing difficulty in the breathing passage. So I was referred this patient because we have handled cases like this before. So we did perform what we call the exit procedure where we are able to put in a breathing tube into the respiratory passage of the baby while the baby is still attached to the mother and its mother's circulation is still continuing. So we call this the exit procedure called the extrautriene intrapartum treatment that is given to babies where we anticipate difficulty in breathing of the baby and difficulty in putting a tube into the baby after delivery. So we do that while the baby is still having its maternal blood supply and oxygen supply from the mother. So the exit procedure, the extrautriene intrapartum treatment what we do is for patients for babies with difficulties in breathing. Now when does this happen? If there is a tumor in the neck pressing the larynx or the voice box or the trachea, the windpipe, these babies are likely to have difficulty in breathing or in putting in a tube to help them breathe. So in these kind of conditions these are picked up antinately by ultrasound and they are referred to us and so we have a wonderful team of doctors including the neonatologists and the anesthesiologists who we work as a team. So we deliver the baby in half, we perform a caesarean, we deliver the head of the baby and before we deliver the full baby and cut the cord and separate the circulation what we do is we deliver the baby. So the baby is still attached to the mother receiving its blood supply and oxygen from the mother. At that point of time the anesthetists or the neonatologists come in and intubate the baby, intubate meaning putting in a tube into the windpipe of the baby. So if at all they have any difficulty they use some extra equipment to visualize well and put it so that the baby does not get compromised in terms of oxygenation. If the baby is separated from the mother then the baby is trying to breathe on its own and if we are not able to put in a tube then the baby gets into trouble. This way we secure and we make sure the baby is 100% safe before we actually separate it from the mother. Anesthesiologists play an important role because we have to deal with the mother and the unborn fetus. So we have to plan accordingly it is a huge team work which involves not only the doctors but also our technicians and other paramedical staff inside the operation theatre. Some modifications in anesthesia technique is also required where we have to general anesthesia is the choice basically so that we have things well under control. The mother is put to sleep and with routine monitoring in addition to the routine monitoring we will have to do some invasive monitoring along with and then we anesthetize the fetus so that the fetus does not move when we try to secure the airway. So once the mother is anesthetized the fetus is also anesthetized and regular caesarean section is performed as the head of the baby is delivered we get into the picture where we try to secure the airway one of the upper limb of the baby is also brought out and we put a pulse oximeter to monitor the baby and we try to secure the airway with we have a protocol kind like first we try to go ahead with the routine laryngoscopy and securing of the airway. The next step if we have problems we can use supraglottic airway devices if that also fails then we have to have a plan C where the surgeons get involved the baby cord is clamped and the baby is secured with the airway we hand over the baby to the pediatricians to take care. As it's been already highlighted by everybody what exit procedure means now I'd like to give a little more salient features where it involves a lot of planning by multidisciplinary thing first is a meeting of all the multidisciplinary who are involved and then everybody should be clear with the action one plan A plan B plan C depending on what is the first priority six cases that we have done we've been able to successfully secure the airway and get the child out without any hypoxic damage. So main important thing is this placental circulation is used to prevent the hypoxic damage while we secure an obstructed airway that is been diagnosed in utero by the ultrasonologist. So this is where we the planning of exit procedure helps in getting the child with the minimal cerebral damage or anything because of hypoxia that's the main goal of exit procedure. Our neonatal perinatal unit here at Manipal Hospital Bangalore receives a lot of antenatal referrals where the baby who has been found to have a compromised airway even before birth that is in utero that is in the antenatal period when scans are done sometimes babies are found to be having tumors in the neck like this baby or sometimes there are tumors inside the mouth or compromising the organs which are the wingpipe inside the mouth or something extensively is pressing the wingpipe from outside. Sometimes there are babies who are born without a diaphragm so called congenital diaphragmic mitochondria. These are babies who are referred here for the exit procedure which you do normally in these instances. Now this baby after the exit procedure successfully could establish a secure airway for this baby we then transported this baby to our neonatal intensive care unit in Manipal Hospital Bangalore where this baby was connected to a ventilator to give supportive respiratory care for this baby. We then contemplated what is the best care for this baby and investigations including an MRI which is done with contrast was determining that this was a tumor which was vascular in origin. So we adopted a very conservative approach in management where we used a special medicine called propranolol which slowly shrunk the tumor so that over the next two weeks this baby could be got off the ventilator and including oxygen support. Today we are very happy to tell you that this baby is breathing normally on her own and she is even able to breastfeed and she is off any kind of respiratory support and we do expect that this tumor which is already considerably shrunk is probably going to shrink further in size and the baby should not have any problem and we are going to discharge this baby healthy and happy home to a mother who is very happy to receive this baby. This is the success story of the exit procedure in this baby we wanted to share with our audience here today. Thank you.