Fetoscopic Surgery
These instructions contain information for patients scheduled for fetoscopic surgery at Children's Hospital of Philadelphia (CHOP).
Important information:
Fetoscopic surgery is a procedure done on an unborn baby in the uterus. You may hear your team call this operating on a "fetus in utero." The procedure is minimally invasive and avoids a large incision on the skin and the uterus.
Fetoscopic surgery is a treatment for certain problems with a pregnancy or a fetus. Operating on the fetus or placenta before birth may help correct the problem. This allows for improved fetal outcomes and a better chance for the baby's survival after birth. At the Richard D. Wood Jr. Center for Fetal Diagnosis and Treatment at Children's Hospital of Philadelphia (CHOP) several types of problems may be treated with fetoscopic surgery before birth. The healthcare team and specialists that you meet at our center will explain your fetus's problem in detail and describe the goals of fetoscopic surgery.
The purpose of this information is to provide details about your medical evaluation, hospital stay and care after discharge from the hospital.
Our goals are to calm your fears, ease your concerns, answer your questions, and to help you be involved in your care.
Meeting the team
As you prepare for fetoscopic surgery, you will work with a variety of healthcare providers who are members of the Fetal Therapy Team. Each person will play a role in your care.
Your team will include:
Nurse coordinator
The nurse coordinator will be your primary contact person and will be available to help you throughout your course at Children's Hospital of Philadelphia. They will speak to you before your visit and describe what will happen while you are here. They will talk to you about medical issues and coordinate the services that you need. They will arrange and coordinate your appointments with ultrasound and echocardiography.
Genetic counselor
You will have the opportunity to meet a genetic counselor. They will help you and your family understand the information about genetic tests and their impact on your child's condition. They will review your family's history, the available options for your pregnancy, and help you to make the best choices for your family's goals and values.
Perinatologist and maternal-fetal medicine (MFM) specialists
Perinatologists, obstetricians and MFM specialists are doctors who care for patients with high-risk pregnancies and fetuses with defects diagnosed before birth. These doctors will speak with you about your baby's condition. They will discuss different management options. If surgery is recommended, they will explain the risks, the benefits, and the possible complications. They will oversee your care after surgery.
Pediatric cardiologist and echocardiographer
This specialist will use ultrasound to examine the structure and function of your baby's heart. This specialized ultrasound is called an echocardiogram. It is sometimes called an "echo" for short. The echocardiographer, the person who does the echocardiogram, will also check the fetus after surgery, if indicated. Additional fetal echocardiograms may be needed throughout the rest of your pregnancy.
Radiologist/sonographer
This specialist will do a very detailed ultrasound to help diagnose your unborn baby's problem. The sonographer will also assist during fetal surgery and check the fetus during your recovery time.
Anesthesiologist
An anesthesiologist will provide anesthesia for you and your unborn baby. They will meet with you before surgery to discuss your medical and surgical history. They will explain the plan to keep you comfortable during your surgery. Fetoscopic surgery is usually done under conscious sedation. This means that you will be given medicine through an intravenous catheter (IV) to sedate you and help you relax. This medicine may help the baby to stay quiet during the surgery. The anesthesiologist will take care of you during the procedure. They will provide sedation and monitor your vital signs.
Advance practice nurse (APN) and obstetric nurses
The advanced practice nurse will meet with you before surgery to review your medical and surgical history and perform a physical exam. They will discuss your hospital experience and home care with you. They will follow your progress before and after surgery. The APN will be your contact person after surgery. Please call the APN at any time before surgery, during recovery, or after you leave the hospital.
During your hospital stay your nursing care will be done by the obstetrical nursing staff. They will help you to recover from surgery, provide pain relief, manage medicines to prevent premature labor, and monitor your unborn baby.
Social worker
A social worker may meet with you and your support person to help you find ways to cope with the stress of this situation. They will talk to you about the social, emotional, and financial issues facing you and your family. They will coordinate the social services that you need. If needed, they can speak with your employer and help with insurance issues. The social worker can help with housing arrangements for your stay in Philadelphia. They will help you after you are discharged from the hospital.
Operating room nurses
The nurses who assist the surgeons in the operating room often meet you before surgery and can answer questions about the procedure. You will also see them briefly when you arrive in the operating room on the day of the surgery.
Pre-surgery planning
Here are some ideas to help you prepare:
Support
It is very important to have a good friend or family member stay with you while you are in Philadelphia. Most patients are asked to stay in Philadelphia for 5-7 days after their surgery. During that time your activities will be limited so you will need someone to help you. This is a stressful time, and you will need to be with someone you trust.
Family meeting
Members of the Fetal Surgery Team will meet with you and your support people to discuss the results of your tests, your history and physical exam. They will answer your questions. Each person will talk to you about your baby's diagnosis as it relates to their specialty. We will support whatever decision you make. If you choose not to have surgery, we will arrange for the best possible care before, during and after birth for both you and your baby.
If you choose to have surgery, these will be the next steps:
Before surgery
The day before your surgery will include testing and meetings. You will have a chance to discuss any concerns that you or your family may have. The APN will meet with you before surgery to review your medical and surgical history, perform a physical exam, and discuss what to expect during your hospital stay and home care with you. If needed, blood samples will be collected for testing.
You will meet with the anesthesiologist to discuss your medical and surgical history. They will explain the plan to keep you comfortable during your surgery.
If you have not met with or spoken to the social worker, you may have an opportunity to do so on the day before surgery.
You will also meet with a member of your MFM/obstetrical team. Your procedure will be discussed in detail and any last-minute questions you may have will be answered. You will review and sign the surgery consent.
The night before surgery it is important to eat a light meal and drink as much water as you can, to prepare your body. Do not eat anything after midnight. You can drink clear liquids, such as water or apple juice, until the time your team instructed you.
The night before or morning of surgery you will take a shower with an antibacterial soap.
On the morning of surgery, come to the Garbose Family Special Delivery Unit (SDU). The SDU is located on the 6th floor of the West Tower. You will be given a scheduled arrival time. A nurse will greet you and escort you to your room. You will change into a hospital gown and the nurse will check your vital signs. An intravenous (IV) catheter will be placed in a vein in your arm. You will have a vaginal ultrasound to check your cervix. You may be given several medicines before surgery.
During surgery
The anesthesiologist, the nurse and the sonographer will go with you to the operating room. The doctors, other nurses and technicians will be there to help with your care.
First, you will be asked to lie down on the operating table. Compression stockings will be placed on your lower legs to help prevent blood clots from forming in your legs. An ultrasound will be done to determine the position of your baby. You may need to lie on your side during the surgery. When you are positioned correctly, you will be given medicine through your IV to sedate you and help you relax.
You and your baby will be monitored closely during the surgery. Your family can stay in your room on the Special Delivery Unit. A nurse will give them regular updates about your progress.
Post-operative recovery
After surgery you will be cared for on the Special Delivery Unit. When you wake up from sedation, you may be connected to a variety of tubes and equipment. This equipment will monitor or treat you and your baby. These may include:
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One or more IVs controlled by pumps
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An oxygen mask or nasal oxygen prongs to help you and your baby get enough oxygen
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An electronic monitor to watch for uterine contractions
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A blood pressure monitor
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Compression boots on your legs to help prevent blood clots
Any tiny abdominal incisions will be covered with a simple clear dressing so that your baby can be monitored more easily. The site can be checked without having to remove the dressing.
Post-operative care
You will be closely monitored by the Fetal Therapy Team during your hospital stay. We will keep a very close eye on your progress. You will have a belt around your stomach to monitor contractions. Preterm labor is the most common complication of this surgery. You may continue to receive medicines to help control this. Depending on the type of surgery you had, you may be discharged from the hospital later in the day or the following morning.
Post-operative medicines
To reduce your chances of preterm labor, you may receive some of the following medicines:
Indocin® (indomethacin)
This medicine helps your body stop making prostaglandins that can cause uterine activity. This means it can help your uterus relax. It is a pill that is given one hour before the surgery and then may be given for 24 hours after the surgery. The most common side effects are stomach upset and a temporary decrease in amniotic fluid.
Magnesium sulfate
Magnesium sulfate has many uses, including muscle relaxation. In this setting it is used to relax the uterus and decrease contractions. Your healthcare team will closely monitor your response to the medicine. Magnesium sulfate leaves your body through your urine, so we will keep a record of your fluid intake and urinary output. Your fluids will be limited while you are on the magnesium sulfate, usually for 12 - 24 hours. We may draw blood to check the levels of the medicine in your system to make sure that side effects are limited. Possible side effects of magnesium sulfate include:
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Feeling of warmth
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Sweating
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Dry mouth
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Muscle weakness
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Nausea and vomiting
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Feeling sleepy or tired
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Blurred vision
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Fluid in the lungs
After 12-24 hours, we will slowly decrease your dose of magnesium sulfate and then change to another medicine to help control your contractions.
Nifedipine
Nifedipine decreases smooth muscle contractions and relaxes the uterine muscles. This medicine is a pill, which is taken by mouth every 6 hours. Possible side effects of nifedipine are:
Pain management
Some patients who have had fetoscopic surgery have no pain or discomfort. However, if you have any pain or discomfort after the surgery, medicines will be ordered for you.
Antibiotics
Since infection is possible with any surgery, you will be given antibiotics through your IV in the operating room. You may also be given antibiotics through your IV for 24 hours after the surgery. If you are going home the same day as your surgery, you may be given a prescription for oral antibiotics. You will be given instructions for taking the medicine before discharge. The team will monitor signs and symptoms of infection. Please let us know if you are allergic to any antibiotics.
Activity
After your surgery, you will need to stay in bed, resting on your side. This position increases blood flow to your uterus, which provides blood to your baby. It also helps decrease contractions. Your nurse will assist you to the bathroom. You will be advised to limit physical activity for a few weeks after surgery.
Diet
The sedation medicines may cause nausea and vomiting. You will slowly be given fluids to drink. Once you can keep fluids down, you may have solid food.
Preterm labor
While you are in the hospital, you will be closely monitored for signs of preterm labor. If you experience any of the following after surgery, please tell your healthcare team. The signs and symptoms of preterm labor are:
Discharge planning
To safely go home you must meet the following goals:
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Have no more than 6 contractions in one hour
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The fetus's heart rate is normal
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Walk from your bed to the bathroom
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Empty your bladder without pain or urine retention
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Eat a normal diet without nausea or vomiting
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Understand your home care instructions and any medicines you may be prescribed
Post-surgical visits
A follow-up ultrasound and possibly a fetal echocardiogram will be scheduled for 5-7 days after your surgery. You will be given the date and time of these appointments before you are discharged from the hospital.
After the follow-up visit you will return home and be cared for by your regular obstetrician. They will care for you through the rest of your pregnancy and delivery.
Recovery after discharge
Activity
After your discharge your level of activity may be limited for 2-3 weeks. Follow the instructions from your provider to gradually increase your activity after your follow-up appointment.
Diet
Eat a balanced and nutritious diet. Drink 6 to 8 glasses of water a day to help avoid constipation.
Delivery
The goal is to carry your pregnancy as long as possible to avoid the problems that come from prematurity.
Patients who had fetoscopic surgery may go on to have either a vaginal or cesarean delivery. Your delivery plan will be determined by your obstetric care team.
Contact your CHOP healthcare team with questions, concerns or if:
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If your incision, the cut on your stomach, has signs of infection such as redness, warm or tender to the touch or is draining.
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You have a fever 101 degrees F (38.5 degrees C) or greater
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Fluid leaks from your vagina
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You have vaginal bleeding
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You feel the baby move less than 10 times each day after 28 weeks of pregnancy
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You have persistent back pain, cramping, abdominal tightening or pelvic pressure
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You have chest pain or difficulty breathing
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You have changes with urination like pain or burning, blood in the urine, or it has a strong foul smell
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1-800-IN-UTERO (1-800-468-8376) and ask for the attending OB or midwife on call.
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If you are having difficulty reaching the on-call provider, please call:
The Garbose Family Special Delivery Unit
267-425-6900
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Reviewed on May 4, 2023, by Shawnese Duren MSN, CRNP/CNM, RNC-OB; Shelly Soni MD