July 18, 2013

Teamwork drives Maternal Fetal Medicine program

When Steffanie and Jon Sawyer were told their unborn son had a spinal birth defect called spina bifida, they decided to travel from their home in the Chicago area to Vanderbilt for fetal surgery.

Kelly Bennett, M.D., makes the initial incision on patient Steffanie Sawyer during the fetal surgery procedure to close the spinal defect of Sawyer’s unborn son. (photo by Daniel Dubois)

When Steffanie and Jon Sawyer were told their unborn son had a spinal birth defect called spina bifida, they decided to travel from their home in the Chicago area to Vanderbilt for fetal surgery.

“Vanderbilt was recommended by our Children’s Hospital experts here in Chicago because they had done so many of these, and because we could return home for delivery,” said Jon Sawyer.

The surgery in February went well, and the couple returned home, delivering baby William Perry on May 1.

While the Sawyer family’s story is no longer unusual, it illustrates how Vanderbilt’s reputation as a nationwide center for maternal fetal care has developed in the two years since the landmark results of the Management of Myelomeningocele Study (MOMS) were published in the New England Journal of Medicine.

The seven-year MOMS trial proved fetal surgery offers significant benefits to many babies with spina bifida.

Several centers nationwide now provide the surgery, but Vanderbilt’s Division of Maternal Fetal Medicine within the Department of Obstetrics and Gynecology stands out as one of the few centers that uses specialists in both pediatric care and obstetrics — working as a team — to focus on both the mother and the unborn baby in equal measure.

Because of their focus on the broader aspects of care for families, Vanderbilt specialists developed ways to determine if women, like Steffanie Sawyer, could safely return to their homes for pregnancy care and delivery after fetal surgery; a major benefit, especially for families who have other children at home.

Steffanie Sawyer gets one final utrasound before the surgery to repair her unborn son’s spinal defect. (photo by Daniel Dubois)

Kelly Bennett, M.D., director of the Division of Maternal Fetal Medicine, said the teamwork focus at Vanderbilt has helped to develop an approach that is heavily collaborative and rare among fetal care centers.

“In order for us to have the best outcomes we have to have everyone doing their job with a great deal of expertise and I think that is the strength of Vanderbilt. We have a very collegial group that works very well together and we care very deeply about our patients and their babies,” Bennett said.

Noel Tulipan, M.D., professor of Pediatric Neurosurgery, said his surgical repair of an unborn baby’s open spine has not changed much since he pioneered the technique in the 1990s. However, he said his colleagues on the obstetric team continue to make strides to improve prematurity outcomes in fetal surgery.

“We have a manuscript that will be published soon describing the changes in the obstetric technique, but our results as far as prematurity are actually better than they were using the MOMS protocol.

“Kelly Bennett and her obstetrics team are really good and have reduced prematurity rates. Prematurity is our major side effect from the procedure,” Tulipan said.

While the fetal repair of spina bifida surgery may be the center’s best-known procedure, it is far from the only service provided in the Junior League Fetal Center at Vanderbilt. Average volumes for procedures have more than doubled; from 128 a month in 2010 to 270 a month in 2012, and outreach clinics have opened in Clarksville, Columbia and at Vanderbilt Health One Hundred Oaks.

Obstetricians from around the region send patients to Vanderbilt for targeted ultrasound and diagnostics. Defects diagnosed regularly include gastroschisis, cardiac defects, cleft lip and palates, and hydrocephalus, all defects that are commonly treated by pediatric specialists at Vanderbilt.

Vanderbilt also performs “exit procedures.” When a baby is suspected to have a serious airway obstruction at the time of delivery, C-section deliveries can be done at the Monroe Carell Jr. Children’s Hospital at Vanderbilt.

The maternal surgical team partially delivers the baby while keeping blood and oxygen flow maintained through the placenta. Then pediatric surgeons stabilize the baby for delivery, and if necessary can take the baby to an adjacent pediatric operating room after delivery.

Perinatal Clinical Nurse Specialist Nancy Townsend, R.N., MSN, said fetal surgeries or exit procedures are a small portion of the care provided, but they highlight the collaboration that has been cultivated at Vanderbilt over many years.

“The teamwork and planning beforehand is amazing, right down to almost a choreography of where the surgical teams will stand and where they will move.

“The goal is always seamless teamwork for safer, better care. Visiting physicians comment on how well the teams work together, and we see more international experts coming here to see how we do this,” Townsend said.

To view a video story about the Sawyer’s fetal surgery, go to www.mc.vanderbilt.edu/reporter/.