These defects in the abdominal wall should be readily apparent on observation. Management of gastroschisis and omphalocele from delivery to transport is nearly identical and should be initiated once either diagnosis is suspected.

In addition to the routine neonatal resuscitative measures outlined in Chapter 36, the goals of stabilizing these infants are to minimize heat and fluid loss and to prevent desiccation, injury, or infection of the exposed viscera. Care must be taken in placing the umbilical cord clamp so as to avoid injury to the herniated intestine.

The infant is placed under a radiant warmer, and the exposed viscera are protected with a warm, sterile, saline-soaked dressing. The exposed viscera should be inspected to ensure that it is not twisted or kinked, which can result in vascular or caval obstruction. A change in color of the exposed bowel from pink to gray may indicate the presence of such an obstruction. Tension on the mesentery may be reduced by supporting the bowel on packs of warm, sterile, wet gauze (2). As soon as possible, the infant should be placed in a sterile intestinal bag with the drawstring tied around the chest (Fig. 39.2A). If the infant is small, the arms also can be enclosed (1). This clear plastic bag has the following advantages: heat and fluid loss are minimized, and it allows the physician to observe the color of the bowel, looking for signs of ischemia. An 8 to 10 French nasogastric tube should be placed to free drainage and should be aspirated every 10 to 15 minutes to prevent vomiting and to keep the bowel decompressed. Fluid resuscitation should be initiated with 10 to 20 mL/kg of colloid, Ringer lactate, or normal saline solution. Maintenance fluids of D10 ¼ normal saline should be started at twice the calculated normal maintenance volume and continued until the urine output is 2 to 3 mL/kg/hour (4). Broad-spectrum antibiotics (ampicillin and gentamicin) should be started after a baseline blood culture is obtained. Transport should be promptly arranged to a tertiary care center with an available neonatologist and pediatric surgeon.

Gastroschisis is considered a surgical emergency and should be corrected as soon as possible. In the surgical management of these defects, the infant is stabilized either by fascial or skin closure or with construction of a prosthetic sac (called a “silo”) enclosing the herniated viscera (5). Small omphaloceles (5 cm or less) usually can be closed primarily. Larger defects are repaired either by closing skin but leaving a vertical hernia that can be repaired later or by constructing a silo that is compressed on a daily basis. When the contents of the site are completely reduced into the abdomen (usually in 7 to 10 days), fascial closure is possible (5).

Despite the measures already described, the infant may arrive at the accepting hospital with problems related to hypothermia, volume depletion, acidosis, or all three (2). Insensible fluid loss is minimized by the overlying plastic wrap but must be watched closely to avoid drying of the viscera or hypovolemia in the patient. Excessive handling of the bowel may predispose to infection or injury.

The bladder should be covered by plastic film wrap such as Saran or Glad or by Vaseline gauze (4). Antibiotics are not necessary. The infant should be transferred to a neonatal unit for further evaluation. Repair is done electively in stages, beginning in the neonatal period with the ultimate goal of closing the bladder, reconstructing the abdominal wall, genital reconstruction, and eventual urinary continence.