Case study #2: Child with Spina Bifida, Myelomeningocele, Chiari II Malformation, and Hydrocephalus
Drew is admitted to the neonatal intensive care unit (NICU) immediately after delivery. The admitting diagnosis is a neural tube defect. Drew was full term at birth, with a birth weight of 3.2kg (50th percentile) and length of 19.8 cm (50th percentile). Drew’s mother is a 37 year old with a history of three miscarriages. Drew is her first child. The pregnancy was a “surprise,” and the mother was not aware she was pregnant until 12 weeks post-conception. She was financially unable to receive consistent prenatal care and has had no prenatal screening. Upon admission to the NICU a complete evaluation of the defect is performed. Spina bifida cystica is visible at birth. When the defect is accompanied by a Chiari II malformation, resulting hydrocephalus is expected and signs of increasing ICP are assessed. The neonatologist will perform a complete examination of Drew to evaluate the lesion (sac on back), nerve involvement, and degree of motor and sensory function.
1. The following are the physical examination findings. Identify what these findings indicate:
1. The defect is located at the level of the lumbar spine (L1).
2. The sac is intact, without CSF leakage.
3. The cranial sutures are expanded.
4. The anterior fontanel is bulging.
5. The head circumference is 37.5cm.
6. The lower extremities are atrophied.
7. Muscle tone of the lower extremities is poor (limp and flaccid)
8. The bladder is full and tense.
2. Drew is scheduled for surgical closure of the sac the following day. The NICU staff begins preoperative care measures for prevention of the infection. The focus of the preoperative care for the neonate or the child with myelomeningocele is on maintaining integrity of the sac to prevent CSF loss and infection (meningitis).
The following care interventions are instituted. Provide a rationale for each intervention.
a. Position the neonate on the abdomen.
b. If the child is prone, place a cloth roll under the hips.
c. h. Intermittent urinary catherization is performed.
d. There is assessment for signs and symptoms of meningitis.
3. Explain the additional preoperative care considerations for Drew:
a. Nothing by mouth (NPO)
b. Fluids at two-thirds maintenance rate.
c. Latex precautions
d. Neurologic assessment every 2 hours.
4. Could the defect have been detected before delivery (prenatal diagnosis)?