Congenital diaphragmatic hernia is a birth defect where there is an opening in the diaphragm that allows abdominal organs to move into the chest cavity. This compresses the lungs during development and causes pulmonary hypoplasia and hypertension. The defect occurs in about 1 in 5,000 births and is most often a left-sided opening. While the exact cause is unknown, risk factors include smoking and genetic conditions. Treatment involves prenatal surgery to repair the diaphragm if possible or intensive postnatal care including ventilation support, surgery to return organs to the abdomen, and management of pulmonary issues. Nursing care focuses on stabilization, monitoring, reducing stress, and supporting the parents through the serious condition and treatment

1. Congenital
Diaphragmatic Hernia

2. DEFINITION:
Congenital Diaphragmatic Hernia is an opening between the
thorax and abdominal cavity due incomplete development of
diaphragm. This results in intestines and other abdominal
structures, such as the liver, can enter the thoracic cavity,
compressing the lung. Lung growth may be arrested on the
affected side. pulmonary hypoplasia and pulmonary hypertension
occur due to compression of the lung, including the airways and
blood vessels. This serious defect requires prompt recognition
and aggressive treatment to reduce its high mortality.

3. INCIDENCE:
The incidence of CDH is 1 in 5000 live birth, and most
common type of CDH (90%) is a left posterolateral defect,
also known as a Bochdalek hernia because the herniation
occurs through the foramen of Bochdalek

4. ETIOLOGY:
• CDH occurs due to the incomplete formation of the diaphragm
during fetal development.
• The exact cause remains unknown, but it is believed to involve
a combination of genetic and environmental factors.
• Some associated risk factors include maternal smoking, certain
medications, and chromosomal abnormalities such as trisomy 21
(Down syndrome).

5. PATHOPHYSIOLOGY:
In CDH, a defect in the diaphragm allows abdominal organs,
typically the intestines, stomach, and liver, to herniate into the
chest cavity.
This herniation leads to pulmonary hypoplasia (underdevelopment
of the lungs) and pulmonary hypertension, impairing respiratory
function.
Compression of the developing lungs by herniated abdominal
organs further exacerbates lung growth impairment and
compromises gas exchange.

6. CLINICAL MANIFESTATIONS
Common clinical features include cyanosis, tachypnea,
retractions, scaphoid abdomen(because of abdominal contents
in the chest); and diminished breath sounds on the affected
side.
If pulmonary hypertension is severe with decreased pulmonary
venous return, right atrial pressure will be greater than left
atrial pressure, resulting in shunting of blood through the
foramen ovale. The net results of these events cause further
hypoxia, hypercarbia, and acidosis.
In severe cases, CDH may be associated with impaired cardiac
output , such as hypotension and shock.

7. DIAGNOSTIC EVALUATION
 Prenatal diagnosis by ultrasonography as early as 25 weeks of
gestation is possible, typically revealing characteristic findings
such as polyhydrominos, mediastinal shift and bowel loops in
the chest cavity.
 Postnatal diagnosis is confirmed through chest X-ray, which
demonstrates the presence of abdominal contents in the thoracic
cavity and lung hypoplasia.
 Echocardiography is essential to evaluate associated cardiac
anomalies and pulmonary hypertension.

8. THERAPEUTIC MANAGEMENT:
Intrauterine Repair:
Fetal surgery techniques have evolved to enable intrauterine repair of CDH in
select cases.
This approach aims to correct the diaphragmatic defect and promote lung growth
before birth, potentially improving postnatal outcomes.
Tracheal Obstruction: Tracheal occlusion, a fetal surgical technique, PLUG (Plug
the Lung Until it Grows) and EXIT (Ex utero Intrapartum Treatment) involves
blocking the fetal trachea temporarily.
The obstruction creates a pressure gradient that promotes lung expansion and
facilitates the return of abdominal contents into the abdomen, fostering the
development of larger, functional lungs.

9. SURGICAL REPAIR:
 Increased survival rates have been reported with surgery after a
period of preoperative stabilization.
 Place the infant on extracorporeal membrane oxygenation
(ECMO) or high-frequency ventilation. Operative treatment
involves returning the abdominal organs to the abdomen and
repairing the diaphragmatic defect.

10. NURSING CARE MANAGEMNT:
AFTER BIRTH: Immediate Stabilization:
 Immediate assessment and stabilization are crucial, focusing on
airway management and respiratory support.
 Endotracheal Intubation and mechanical ventilation, G I
decompression with double lumen catheter to prevent further
respiratory compromise are often required to address
hypoxemia, hypercarbia, and respiratory acidosis.
 At birth, bag and mask ventilation is contraindicated to
prevent air from entering the stomach and intestine.
 In infants with mild respiratory distress, oxygen may be given
by hood monitoring the infant's acid-base status to prevent
pulmonary hypertension.

11.  Low ventilatory positive pressure and the lowest mean airway
pressure possible, combined with rapid ventilatory rates (80 to
120 breaths/min), may reduce the incidence of pulmonary
leaks from overinflation of the unaffected lung.
 IV fluids are initiated during the stabilization period.
 A pulse oximeter may be placed preductally (right hand) and
postductally (left hand, arm, or either foot) to monitor the
amount of ductal shunting through the patent ductus
arteriosus.
 An umbilical arterial catheter will allow infusion of fluids,
glucose, and electrolytes.

12. • Close attention to the infant's thermoregulatory status
(maintain neutral thermal environment) and glucose
requirements during the acute phase is another priority of care
• Surfactant replacement therapy may also be used to
stabilize neonates with CDH .
• The use of inhaled nitric oxide to relieve pulmonary
hypertension

13. Post operative care:
 Postoperative nursing management involves continuation of
ventilatory therapy, monitoring of acid-base balance, and even
maintaining the infant in a slightly alkalotic state to prevent or
decrease the effects of pulmonary hypertension.
 In addition, gastric decompression, thermoregulation, sedation,
and maintenance of adequate cardiac output and peripheral
perfusion can continue
 Nursing care of the infant with a CDH is also aimed at reducing
stimulation either from care activities such as routine
suctioning or from environmental factors such as noise and
light.

14.  Measures that further reduce infant stress, such as
management of pain, should be a routine aspect of care for
the infant with a CDH.
 Because of the serious nature of the condition and the
urgency of treatment, the parents are in great need of ongoing
support and education regarding postoperative care.
 The infant with a CDH may require long-term hospitalization
and care. As soon as medically possible, the parents should
be involved in the daily care of their child.

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