Neural tube defects are abnormalities that occur in the brain, spinal cord or spine of a

developing fetus, occurring in the first month of pregnancy (National institute for health, n.d).

Myelomeningocele is one of the most sever forms of spina bifida, it is a condition where the

fetus’ spinal cord fails to close during development (Cardinal Glenon Childrens hospital). On the

other hand, hydrocephalus or “water in the brain” is defined as excess cerebrospinal fluid

accumulation int the head caused by disturbance of formation or flow or absorption.

Hydrocephalus occurs in 15-25% of children with open myelomeningocele. Hydrocephalus

affects approximately 1 in every 500 children, the majority occurring prenatally. The cause of

hydrocephalus is not completely understood, but has been associated with genetic inheritance,

complications of preterm birth, prenatal maternal infection, perinatal infection or injury,

childhood tumors, or subarachnoid hemorrhage. According to the National Information Center

for Children and Youth with Disabilities, “Approximately 40% of all Americans may have spina

bifida occulta, but because they experience little or no symptoms, very few of them ever know

that they have it.” The other two types of spina bifida, meningocele and myelomeningocele, are

known collectively as “spina bifida manifesta,” and occur in approximately one out of every

1,000 births. Of these infants born with “spina bifida manifesta,” about 4% have the meningocele

form, while about 96% have myelomeningocele form. The exact cause of myelomeningocele is

not known; however, evidence indicates that genetic predisposition, maternal folic acid

deficiency during pregnancy, and viral infections are strongly associated with the development

of spina bifida.

In the case of Jared, he was delivered via cesarean section to lower the risk for damage to

the spinal cord that may occur during a vaginal delivery. Babies born with a meningocele or a

myelomeningocele usually need to stay in the neonatal intensive care unit (NICU). The main
goals of managing spina bifida are to prevent infection and to protect the spinal cord and nerves

that are exposed outside of the body (Stanford children’s health, n.d). Significant clinical

manifestations that were observed from Jared were bulging fontanels, indicating increased

pressure within the brain and a high- pitched cry; a sign of increased intracranial pressure, which

are symptoms of spina bifida and hydrocephalus. The head circumference of a normal neonate is

within 2.5 cm (1 in.) of the chest circumference; Jerod’s is 6 cm (2.4 in.) larger than his chest.

This further indicates increased intracranial pressure. The sac-like projection in his lumbar

region is consistent with spina bifida. Complications of spina bifida vary depending on the body

system affected and how serious the problem is. Your child may have problems with muscle

function, bones, and bowel and bladder emptying. Babies with spina bifida are at high risk of

developing a latex allergy. This is because they are exposed to latex during the many medical

and surgical procedures they need (Stanford Children’s Health). During admission, priority

would be on reducing risk for injury specially to the sac because of its fragility; decrease risk for

infection; Risk for impaired parent/infant attachment related to Jerod’s being in critical care

environment; Deficient knowledge related to Jerod’s condition, treatment, and home care and

breastfeeding; Ineffective cerebral tissue perfusion related to increased intracranial pressure.

With regards to feeding Jerod, there is no problem with his mom breastfeeding him. The

mom can continue breastfeeding while avoiding the sac, positioning Jerod on his side facing the

breast, this position will also apply post operatively. It is best to encourage breastfeeding all

throughout the care for Jerod. Prior surgery, the priority goal for the nurse is to maintain the

integrity of the sac until surgery. This is accomplished by placing Jerod in a side-lying position

and providing care to the sac according to the health care provider’s prescription. Sac care may
involve leaving the sac open to the air, applying a sterile gauze dressing, a transparent dressing,

or wet-to-dry dressing using sterile normal saline.

Surgical treatment for hydrocephalus involves placing a shunt system. VP shunts are the

most common type of shunt for draining excess CSF. These shunts generally contain a pressure-

sensitive valve that releases CSF once the pressure reaches a certain level. In VP shunts, a

catheter is inserted into the ventricle with tubing tunneled subcutaneously down the thorax and

then further tunnelled into the peritoneal cavity where the CSF is absorbed. This shunt functions

by draining the ventricles of excess CSF and causing it to be absorbed through the peritoneal

wall into systemic circulation and excreted by the kidneys (Rinker et al. 2015). The shunt is a

flexible tube beginning in the ventricle and ending in the peritoneal cavity. The atrioventricular

shunts (AV shunts) are much less common and are usually inserted in response to complications

of the VP shunt. The AV shunt drains the ventricle(s) of the brain into the atrium of the heart to

be absorbed into the blood and pumped into systemic circulation by the left cardiac ventricle.

The excess fluid is then circulated systemically and excreted through the kidneys

(Hydrocephalus association, 2017).

As with any surgery, the insertion of shunts doesn’t come without risks. These risks

include mechanical obstruction of the shunt, infection, and subdural hematomas. Complications

may arise either from mechanical complication or biological complication. Mechanical

complications of a shunt include malfunctions such as leaks, obstruction, migration or

discontinuity. Whereas the biological complications of a shunt include, infection, abscess,

pseudocyst, hematoma; and Peritonitis (Rinker et al. 2015).

Prior to the discharge of Jerod the parents should be assessed for their knowledge

regarding Jerod’s condition and surgical treatment. It is imperative that they know what to do
when a problem at home arises. Also, educating them that there is a high risk for infection is a

must, and what could be signs and symptoms of infection. The parents should also be able to

demonstrate infant care, another is them knowing what the signs and symptoms of increased

intracranial pressure are. Follow up care is encouraged.

 References

National Information Center for Children and Youth with Disabilities. (2004). General

information about spina bifida. http://www.nichcy.org

Rinker, EK, Williams, TR & Myers, DT 2015, ‘CSF shunt complications: What the abdominal

imager needs to know’, Abdominal Imaging, February, viewed august 13

2020, https://www.researchgate.net/profile/Todd_Williams5/publication/27s_to_know/links/

54da115d0cf25013d043e628.pdf

Hydrocephalus Association. (2017). Hydrocephalus. viewed August 13,

2020, http://www.hydroassoc.org/complications-of-shunt-systems/

Stanford Children’s Hospital. Spina Bifida in Children. (2020).Spina Bifida in Children. (n.d.).

Retrieved August 13, 2020, from https://www.stanfordchildrens.org/en/topic/default?id=spina-

bifida-90-P02415#:~:text=You may need to have,intensive care unit (NICU)

Fetal Hydrocephalus: Causes, Diagnosis & Treatment. (2020). Retrieved August 13, 2020, from

https://www.ssmhealth.com/cardinal-glennon/fetal-care-institute/head-spine/hydrocephalus