Nanda Diagnosis

spina bifida is abirth defect that occurs when the spinal cordfails to form properly, leaving a section of the spinalcord and spinal nerves exposed through an opening inthe unborn baby's back. there are several scientificnames for spina bifida. it is also knownas myelomeningocele or meningomyeocele. although there are manytheories about why this happens, the exact cause ofspina bifida is unknown.

however, we do knowthat spina bifida a occurs early in pregnancyduring the development of the spinal cord,typically about 35 to 42 days since your lastmenstrual period or lmp. this rare conditionis reported to occur in one out of every 1,500 to2,000 births in the united states every year. to better understandthe problems associated with spina bifida, let's firstreview the normal development

of the spinal cord. in early fetal life, the tissuethat covers the spinal cord closes like a zipper. this typically begins in themiddle of the spinal cord and closes in bothdirections, toward the head and toward the bottomof the unborn baby. this process starts at about35 days into fetal life. at 36 days since yourlast menstrual period, there is almost completeclosure of the spinal cord,

with only small openingsnear the head and bottom. by 42 days since yourlast menstrual period, there should be complete closureof the spinal cord, also known as the neural tube. however, failure of the neuraltube to completely close will result in aneural tube defect. if the tissue fails toclose near the fetus's head, a condition known asanencephaly can occur. failure of the tissue to closeat the bottom end of the fetus

results in a myelomeningocele,or spina bifida. here you can see thedifferences in development of a normal fetus incomparison to a fetus with an open neural tube defectat the bottom of the fetus, an example of spina bifida. several variations ofspina bifida can occur. these variations dependon how the neural tube defect continuesto develop, on what is protruding throughthe open neural tube,

and what is covering thespina bifida abnormality. these variations include spinabifida occulta, or hidden spina bifida. this is a covered neural tubedefect where a layer of skin covers the opening in the spine. this form of spina bifidaoccurs in approximately 15% of patients and rarely causesany neurological problems. myeloschesis is thisis a flat neutral tube defect without alayer of skin covering

the opening in the spine. the spinal cord and thesurrounding nerve tissue are exposed to theamniotic fluid. these forms of spina bifidahave similar risks and symptoms as myelomeningoceles. meningocele containsonly spinal fluid that sticks out throughan outpouching or sac through an abnormalopening in the spine. this abnormality does notcontain any nerve tissues.

babies with meningocelehave few or no symptoms, while others may developdegrees of paralysis with bladder andbowel dysfunction. myelomeningocele isthe most severe form of a neural tube defect. it contains both fluid andnerve tissue within a sac. this occurs when the spinalcord or neural elements are exposed through theopening in the spine, which results in nerve damage withpartial or complete paralysis

of the body below the levelof the spinal opening. individuals maybe unable to walk and may have bladderand bowel dysfunction. both meningocelesand myelomeningoceles have a covering of skin with orwithout an outpouching, known as covered neural tube defect. these conditions typicallyhave very mild to no symptoms. during the end ofthe second trimester, you can see the opening of thespinal cord and spina bifida

defect developing. the image on the leftis a view from the side. as you can see,there is an opening in the spinal cord that allowsan outpouching of tissue. this is myelomeningocele. the image on the rightdemonstrates an outpouching from the defect as you lookdown on the fetus's back. the spinal column isdivided into four sections. each segment of thespinal cord corresponds

with a specific regionof sensory, or sensation, and motor, or movement,function in the body. starting from the head, thereare seven cervical vertebrae found in the neck. spinal nerves at this levelsupply movement and feeling to the arms, neck, andupper trunk of the body. next are 12 thoracicvertebrae associated with the chest, followed byfive lumbar vertebrae found in the lower back,and six sacral

vertebrae thatfuse at the bottom to form the tailbone or coccyx. in the normal spineand spinal cord, nerves leave thespinal cord and are numbered according to thevertebrae at which they exit the spinal column. their function is linkedto the level at which they leave the spinal cord. the location ofspina bifida defect

can result in abnormal function. a spina bifida defectis defined based on the level and extentof the bony opening along the spinal canal. the level of bonydefect can help us predict the nerve damagethat a child may experience. the level of thenerve damage may result in loss of sensation orproblems with motor function, including bowel, bladder,and sexual dysfunction.

since most spina bifida defectsare associated with the lumbar spine, which isresponsible for the nerve function in thelegs and lower body we will focus onconsequences associated with these types of defects. in general, the nervesassociated with l1 to s1 are associated with movementand sensation of the lower legs. nerves associatedwith l1 to l3 are responsible forflexing the knee,

whereas nervesassociated with l4 to l5 allow the knee to extend. at the same time, allthe nerves from l1 to l5 are required to providenerve function to the thighs and hips. the motor functionof the foot and ankle are controlled bythe lower nerves. however, all of the nerves inthe lumbar and sacral spine are needed toproperly coordinate

movement of the hips, legs,and feet in order to walk. spinal levels l4 and l5allow one to raise the foot. spinal levels s1 and s2allow one to lower the foot. in general, whenthe spina bifida involves a level above l3,the ability to walk normally is significantly impaired. in addition to the movementof the lower extremities, nerves in the lumbarand sacral regions help control functionsof the internal organs.

since many cases ofspine of spina bifida involve the sacral nerves,children with spina bifida often have problems withurination and bowel control. in later life, sexualfunction may also be affected. typically, childrenwith bladder problems are unable to completelyempty the bladder. problems with bowel controlmay result in soiling. patients with spinabifida may experience some sexual dysfunction,but this may not affect

their reproductive ability. the exact mechanism by whichthe spina bifida defect causes nerve damage is unclear. there are several theories,but the most popular one is a two-hit approach. the first hit is thefailure of the spinal column to properly close, resulting inthe exposure of the spinal cord and its nerves, which may causenerves to abnormally develop. this by itself may or may notdirectly cause nerve damage.

however, a second hitoccurs where the open nerve fibers are exposed tothe amniotic fluid, which can be damaging. and nerves can alsobe directly damaged by trauma due tobumping and rubbing against the uterine wall. in addition to thespinal cord problems, patients with spina bifida candevelop two distinct problems related to the brain, buildupof fluid within the spaces

of the brain, calledhydrocephalus, and a sinking of thelower part of the brain into the base of the skull,known as hindbrain herniation or chiari malformation. in the normal brain,the brain tissue contains and is surrounded bycerebrospinal fluid, otherwise known as csf. normally most of the csf fluidis made by special tissue that lines the openspaces within the brain

called the ventricles. this fluid thenflows around the back of the brain in a regionthat contains the cerebellum and brain stem, andinto the spinal canal to surround the spinal cordall the way to the tailbone. in the case of spinabifida, the defect at the bottom of the spineallows the csf to leak out the opening of the spinalcanal and pulls the brain downward into the base ofthe baby's skull, which is

called chiari ii malformation. this blocks the normalflow of cerebrospinal fluid and causes theventricles to enlarge, a secondary brain abnormalityknown as hydrocephalus. traditionally, spinabifida is repaired shortly after the baby is born. if the defect is diagnosedduring pregnancy, babies with spinabifida are typically delivered by c-section.

because the spinal corddefect does not directly affect the heartor lungs, babies are generally verystable and do not require any immediate treatment. nonetheless, babiesare transferred to the neonatal intensivecare unit for close medication attention. at that point, neonatologistsand pediatric neurosurgeons work together to furtherevaluate the baby

and identify anyadditional problems. they also prepare the infantfor repair of the spina bifida. a pediatric neurosurgeonwill perform the repair within the firstfew days of life, and depending on the severityof the hydrocephalus, infants may or maynot require a tube that drains the excessivefluid from the brain at the same time. this tube is called aventriculo-peritoneal or vp

shunt. babies eventuallyrecover, and once stable, are able to go home. children with spina bifidaare followed very closely by several pediatricspecialists, including a pediatricneurosurgeon, pediatric neurologist,pediatric urologist, pediatric orthopedicsurgeon, and pediatricians who specialize in spina bifida.

in most centers,including the fetal center at children's memorialhermann hospital, spina bifidachildren are enrolled in a comprehensive program toaddress their medical problems, monitor them forlong term problems, and provide support to families. many of the complicationsof spina bifida will not show untillater in life. as mentioned earlier,these may include problems

with walking, boweland bladder function, and neurological development. after the initial repair,future operations and therapy may be needed to treatthe problems associated with spina bifida. for example, vp shunts areplaced to treat hydrocephalus. the vp shunt drains thebuilt-up fluid in the brain into the abdomen, whereit can be absorbed. this treatment can besuccessful in managing

many of the problemsthat can occur in children with spina bifida. although vp shunts areeffective in draining the fluid, they are mechanicaldevices and they sometimes fail due to blockage ormovement and must be replaced. shunts can also becomeinfected and require removal. a baby with spinabifida will usually have several shunt revisionsin his or her lifetime. these treatments address theproblems associated with spina

bifida, but unfortunately cannotrestore the nerve damage that has already occurred. today, alternative optionsexist to treat children after decades ofresearch, surgery to repair the spina bifidadefect before the baby is born, also known as fetalsurgery, is a possibility for babies and mothers whoqualify for the procedure. in early 2011, the newengland journal of medicine published the results of themanagement of myelomeningocele

study, or momstrial, that studied the effects of fetal surgeryfor the repair of spina bifida compared to the routinecare of surgery after birth. this study was sponsored by thenational institutes of health and was conductedover eight years. the primary purposeof the study was to determine if there was adifference in infant death or need for a vp shuntbetween fetal surgery patients and those repaired after birth.

during the eight-yearperiod, more than 1,000 pregnant motherswhose fetuses were diagnosed with spinabifida were initially screened for the study. due to a variety of factorsfollowing additional exams and evaluation, 183patients were randomly placed into two groups with 92to the after birth repair group and 91 in the fetalsurgery repair group. ultimately, the studywas stopped early

when the committee thatwas monitoring the results noted a clear benefitto infants that had undergone fetal surgery. the study results were madepublic in early february, 2011. for patients to be eligiblefor the moms trial, they had to meet specificmaternal and fetal requirements. the fetal requirementsincluded but were not limited to a pregnancyof a single fetus.

pregnancies withtwins were excluded, since the twinwithout spina bifida would be put at higherrisk for premature delivery after fetal surgery. the pregnancy hadto be associated with a single fetusbetween 19 and 25 completed weeks of gestation,which was the time period for potential fetal surgery. to qualify for themoms study, the mother

had to be more than18 years of age. her body mass index, orbmi, had to be less than 35, which is a number calculatedbased on weight and height. a bmk greater than35 is considered to indicate significantobesity and would increase the risk of prematurity. a history of a previousincision on the uterus, such as a classical c-section,puts the pregnant patient at risk for scar separationlate in pregnancy

and therefore wasexcluded from the study. because the riskof preterm delivery is higher in patientswith fetal surgery, mothers with anyconditions or history that increased the riskof preterm delivery, such as short cervix, werealso excluded from the trial. additional risk factorsthat prevented a woman from being includedin the study were insulin dependent diabetes,infection with hepatitis b

or c, hiv infection, redcell aloe immunization, and unwillingness toaccept blood transfusions for various reasons. the unborn baby also had tomeet certain criteria in order to enter the moms trial. these included the presence ofa myelomeningocele beginning with the firstthoracic vertebra, t1, and the first sacralvertebra s1 levels. chiari ii malformationhad to exist

at the time of evaluation. there could be no evidenceof an exaggerated curving of the spine. the spina bifida couldnot be associated with other major fetal anomaliessuch as a heart defect. finally, the fetus had tohave normal chromosomes found by amniocentesis. because of the researchaspect of this study, patients were carefullychosen to maximize

the benefits of fetalsurgery while minimizing the risks to both mom and baby. there were two mainoutcomes of the study. the first was death or need fora vp shunt by one year of age. the designers of the trial feltthat if the children did not receive a shunt byone year of age, they were not likely to needa shunt during their lifetime. the second mainoutcome of the study was to measure themental and motor

development using standardizedtests at 30 months of age. in addition to theoutcomes on the baby, one of the greatestcontributions from the moms trial was theinformation provided on the risks of fetal surgeryfor the pregnant mother. some complications directlyaffected the mother, while others wereeffects of the pregnancy. 6% of women whounderwent fetal surgery suffered from extrafluid on their lungs,

known as pulmonary edema. this often requiresoxygen support but eventually correct itself. problems with the membranesac that surrounds the fetus are a known complicationwith any fetal surgery, and this was certainlyseen in the moms trial. one in four patientswas noted to have a separation of the membranesfrom the uterine wall after the surgery.

membrane separationis a risk factor which may lead to early delivery. membrane separation occurredin almost half of the patients after fetal surgeryand was six times more likely to occur thanwhen the spina bifida repair was postponed untilafter the delivery of the baby. the risk for decreasedamount of amniotic fluid around the fetus, alsoknown as oligohydramnios, was twice as likely tooccur in the fetal surgery

group as a resultof leakage of fluid through the surgical incision. infection rateswere slightly higher in the fetal surgery groups. any fetal surgery is at riskfor separation of the placenta from the uterus, also knownas placental abruption. this can occur at anypoint during the surgery and afterward. depending on the severityof the abruption,

some fetuses may requireemergent delivery. during the moms trial,the obstetricians examined the uterine incisionused for the fetal spina bifida repairearlier in pregnancy at the time of thec-section delivery. they found that thescar was very thin in one out of fourcases, and that there was evidence ofuterine scar separation in an additional 10% of cases.

keep in mind, most ofthese complications are known problemswith fetal surgery and would have only beenexpected in the fetal surgery group of patients. in normal pregnancies,some of these problems can occur but are rare. fetal repair ofspina bifida was also associated withsignificantly increased risks for the newborn.

most of the neonatalcomplications were related to theprematurity at birth. the average gestationalage at delivery was about three weeks earlierin the fetal surgery group, at 34.1 weeks versus 37.3 weeks. 13% of babies were deliveredbefore 30 weeks gestation. an additional one third weredelivered between 30 and 34 weeks, and another onethird were delivered between 35 and 36 weeks.

this means that onlyone in five babies that underwent fetal surgerywere delivered at term. because of theprematurity, birth weight, which corresponds with theirgestational age at birth, was less in thefetal surgery group. the increased rateof prematurity in the fetal surgerygroup was also associated with a 21% incidenceof respiratory distress syndrome seen inpreterm infants,

requiring oxygen and ventilatorsupport in the babies. this was three times higherthan the postnatal repair group. the benefits of fetalrepair of spina bifida appeared to be statisticallysuperior to postnatal repair. the primary outcomeof the study, which was death orneed for a vp shunt in the first year of life,was 30% less frequent in the fetal surgery group thanin the postnatal repair group. the major differencesin the two groups

appeared to be related to theimprovement of the chiari ii malformation in thefetal repair group. babies who underwentfetal repair were half as likelyto need a vp shunt at one year, 40% versus 82%. in addition, whileall fetuses that were entered into thestudy had evidence of hindbrain herniation onmri during their mother's pregnancy, it appeared thatthe chiari ii malformation

was less common andless severe among babies that underwent fetal surgery ascompared to postnatal repair. in fact, 36% of infantswho underwent fetal surgery had no evidence of hindbrainherniation, compared to only 4% in the postnatal surgery group. however, at 12 months, therewas a higher percentage of infants needingoperations for tethered cord syndrome, a condition wherethe spinal cord becomes stuck to the surroundingtissue within the spinal canal,

causing the spinal cordto become abnormally stretched as the child grows. this occurred more oftenin the fetal surgery group compared to thepostnatal surgery. at 30 months of age,neurological outcomes were reviewed and mentaldevelopment in both groups was similar. however, motordevelopment scores seemed significantly betterin the fetal surgery group.

while the abilityto walk depends on the level of thespina bifida lesion, the study found thattwice as many children who underwent fetal surgery werewalking independently as compared to the postnatalgroup, 42% in the fetal surgery group compared to only 21% inthe postnatal repair group. overall, the degree ofdisability in a child was lower among fetalsurgery patients. the moms trial wasa landmark study

in the world of fetal therapy. historically, fetalsurgery was used only for life-threatening conditionsin which the fetus would likely die during pregnancyif left untreated. however, the moms trialwas the first study that demonstrated significantbenefit in children who had undergonefetal surgery for spina bifida, a non-lethal disease. careful analysis ofthe study results

demonstrated the benefitsoutweighed the risks and harms of fetal surgery,including those associated with the mother. although there are still unknownanswers to many more questions, especially those aboutlong term outcomes, it appears that babies whounderwent fetal surgery have benefited inthe short term. unfortunately, the moms trialprovides only statistics, and not specifics aboutyour baby, which is

what all parents want to know. for many families, thiscomprehensive multi-day evaluation and consultationis the first opportunity to meet health careprofessionals who specialize in this condition, andask questions and receive information specific to them. the extensiveconsultation process is designed to help patientslearn about spina bifida and what life is like fora child with the condition.

families also learn aboutall of the treatment options so they have a fullunderstanding of the risks and benefits of conventionaltreatment versus fetal surgery. when patients are referredto the fetal center they undergo comprehensiveevaluation and education consultations. this includes amulti-disciplinary team approach, includingspecialists from both maternal fetal medicineand pediatric subspecialties.

before fetal surgery canbe considered further, thorough counselingand evaluations are provided to ensure thereare no unnecessary risks to the mother, and that the babyis in an appropriate candidate for surgery. early in the evaluation process,families meet a dedicated nurse coordinator fromthe fetal center who will guide them througha step-by-step process that includes the following.

a maternal fetalmedicine specialist will perform a completematernal and pregnancy history evaluation and aphysical examination, and will evaluatethe fetal ultrasound to ensure there are noother complications. families will meet with a spinabifida pediatric specialist, who will provide valuable andunique information on what life is like for spina bifidachildren and their families. the pediatricneurosurgeons will educate

families about spina bifidaand the surgical treatments involved with fetal surgery,as well as postnatal surgery. if it has not already beenperformed by your referring perinatologist. an amniocentesiswill be performed to be sure the fetalchromosomes are normal. in any event, you will meetwith a genetic counselor to review your family'shistory for birth defects. in addition to theconsultation, patients

undergo extensive testing. a comprehensiveultrasound is performed to assess the presence ofthe chiari ii malformation and determine the level ofthe spina bifida defect. a fetal mri willalso be performed, as some features ofthe spine and brain are better seen on mri. mri utilizesmagnetic waves, which are safe during pregnancy.

for mothers and babies whoqualify for fetal surgery, additional consultations andevaluations are necessary. an obstetricanesthesiologist affiliated with the fetal center'smulti-disciplinary team will meet with the mother,assess any anesthetic risks, and explain anyanesthesia concerns. a neonatologist who specializesin critically ill newborns will educate each family aboutthe potential complications of a premature birth.

preterm delivery is a potentialrisk factor of fetal surgery. families will meetwith a social worker to discuss the importance ofthe family and friends support systems. undergoing fetalsurgery is a commitment through the entirepregnancy which requires the help of othersto ensure a safe pregnancy if there are othersmall children at home, a child life specialist atchildren's memorial hermann

hospital will meetwith each family. this individual willprovide valuable tools to help explain the unbornbaby's surgery to the baby's siblings. finally, families willmeet with the fetal surgery specialist who will beinvolved in the surgery. the fetal center'saffiliated team will go over theactual procedure and answer any questionsyou may still have.

fetal surgery is notfor every patient. often patients do not qualifybecause of reasons involving the fetus, and sometimesthey don't qualify because of maternal factors. there are also families whoqualify for fetal surgery but do not think it is the bestoption for them after spending time learning about spinabifida and fetal surgery. for those who qualifyfor fetal surgery, we typically askfamilies to take

a few days to considerall of the options that have been presented with. undergoing fetalsurgery for your baby is a major commitment,and a lifestyle change for the remainderof the pregnancy and future pregnancies. it typically includes afive-day hospitalization following the fetal surgery,three weeks of strict bed rest after the procedure,and weekly ultrasounds

to monitor the fetus andassess for complications of the surgery. more importantly,there maybe prolonged subsequent hospitalizationsduring the pregnancy if complication should arise. membrane separation,preterm labor, or leakage of amnioticfluid may require you to stay in thehospital for the remainder of your pregnancy.

should you elect to proceedwith fetal intervention, your surgery willtypically be scheduled before 26 weeks gestation. fetal surgery for spina bifidais a complicated operation that requires the expertise ofmany physicians and surgeons. two patients areundergoing an operation, the unborn babywith spina bifida, and the pregnant mother. care of the mother starts beforeentering the operating room.

during the morning ofsurgery, the mother and baby undergo another full assessment,including a fetal ultrasound. an epidural forpost-operative pain control is placed before surgery. once inside the operatingroom, the mother and baby are again evaluatedprior to the mother falling asleep withguided anesthesia. meanwhile, theentire surgical team is preparing for the operation.

mothers undergoingfetal surgery are administered generalanesthesia and an epidural for pain control. the skin incision issimilar to an incision used for cesareansection deliveries. as the pregnantuterus is exposed, the well-being of the fetusand position of the placenta is again reevaluatedvia ultrasound. the monitoringprocess is continued

throughout the entire operation. in order to exposethe back of the baby, the uterus is opened with anincision called a hysterotomy. the location of theincision is made to provide the best exposure ofthe spina bifida of the baby. careful attention is madeto avoid the placenta and large blood vesselswithin the uterine wall, as both are importantfor the baby's stability. a stapling device especiallydesigned for fetal surgery

is used to make the incision toprevent unnecessary bleeding. an opening in the uterusis made in an area away from the placentajust large enough to expose the baby's back tosee the spina bifida defect. once the uterus isopen, only the area of the back withthe spina bifida is exposed for the operation. the normal amnioticfluid is removed, and warm fluid iscirculated into the uterus

to replace it duringthe operation. this keeps the fetuswarm and prevents kinking of the umbilical cord. once the baby isproperly positioned, pediatric neurosurgeons repairthe defect in much the same way they would after birth. once the spina bifida isrepaired, the uterus is closed. throughout the entireprocedure, the baby and mother are continuously monitored bythe surgical and anaesthesia

teams. the entire fetal surgeryteam works together to accomplish a very safeand efficient operation for both patients. while the fetal surgery team isworking during the operation, the neonatology teamis on standby, prepared to act quickly if thefetus demonstrates any signs ofinstability that would require immediate delivery.

after surgery, youwill be awakened from general anesthesia andgo to recovery in your room in the labor anddelivery unit, where you will receive one on onenursing care for the first two days. both you and your baby aremonitored during the remaining hospitalization. the first day after surgeryis the most difficult. you will be asked tostay in bed and not

allowed to drink or eat. most patients have a hotand flushed sensation and often describe theirfeeling as losing a day. this is due to amedication called magnesium sulfate that helpsprevent uterine contractions. as you continue toimprove, this iv medication will be changed to anoral medication, which you will continue for theremainder of your pregnancy. you will be slowly encouragedto eat, drink, and get out

of bed over the next few days. the epidural for paincontrol will be changed to oral medications as well. typically, mothers stay atchildren's memorial hermann hospital for five to seven daysfollowing surgery for recovery and evaluation, followed bya two-week stay in houston for further monitoring. often, patients choose totransfer their obstetrical care to an affiliated physician anddeliver at children's memorial

hermann hospital. the team of coordinatorsat the fetal center works closely with familiesto make arrangements for their entirestay in houston. if you choose to returnto your local obstetrician for delivery, the teamat the fetal center will work closely withthe referring physician to ensure an openline of communication and coordinate your carethroughout the remainder

several complicationsmay occur after surgery, and can occur during thehospitalization or thereafter. upon dischargefrom the hospital, patients and their families aregiven very specific monitoring instructions to lookfor signs of problems. these include contractions,leaking of amniotic fluid, bleeding from thevagina, fevers, and separation of the amnioticmembranes based on ultrasound. if you begin to experienceuterine contractions,

please contact the fetalcenter or your family physician immediately, becauseonly 20% of pregnancies reach term deliveryafter fetal surgery. mothers who haveundergone surgery can go into labor at any time. since the fetal membrane aroundthe sac containing the baby were entered duringthe surgery, there is a significant risk ofleaking amniotic fluid. patients will usually experiencefluid coming out of the vagina

when they first stand up. this is a seriouscomplication of the surgery, as it can lead to infection. if this occurs, seekimmediate medical attention. if such leakageoccurs, you will be likely in the hospital for theremainder of your pregnancy. bleeding from thevagina may be a sign of abruption, acritical situation where the placenta isbecoming dislodged

from the uterine wall. because this can haveserious consequences, please contact the fetal centeror your physician immediately. during weekly ultrasoundsafter discharge, the fetal membranesmay become separated this is calledchorioamnion separation. this condition putsyou at high risk for leaking amniotic fluid. if membrane separation isdetected by ultrasound,

you will be admitted to thehospital for observation for the remainderof your pregnancy with potential forearly delivery. in about 20% of casesin the moms trial, patients experiencedno complications and underwent ascheduled delivery by c-section at 37weeks gestation. even though this gestationalage three weeks earlier than the usual due dateat 40 weeks gestation,

your fetal surgery team feelsthat a delivery at 37 weeks is relatively safe for thebaby while minimizing the risks of spontaneous delivery. 37 weeks is also pickedas a time for delivery to keep the fresh scarfrom your fetal surgery from stretching too muchas the uterus gets bigger, and to prevent tearingwith labor contractions. because the heartand lungs are usually normal in babieswith spina bifida,

most infants arestable at delivery but will receivetheir initial care in the neonatalintensive care unit. although the moms trial was awell-designed clinical study, it only providesoverall statistics for the benefitsof fetal surgery compared to postnatalrepair of spina bifida. it incorporated varioustypes of patients with various severities ofspina bifida, all of which

have unique outcomes. although manypatients may medically qualify for fetalsurgery, fetal surgery may not be the right choice forevery mother and her family. many factors go into thisdecision making process, including maternal health andfamily well-being in addition to the overallhealth of the baby. most parents askabout the outcome if they decide on fetal surgery.

although physiciansdo everything possible to minimizethe risks of surgery, there is no way topredict the exact outcome. the fetal center at children'smemorial hermann hospital and the affiliated physiciansat ut health medical school value the importanceof patient education. not every patient willrequire fetal surgery, but every family deservesto be thoroughly educated about their child's conditionand the expected outcomes based

on the specific findingsof their child's condition, as well as a completeunderstanding of how this will affect their child'slife and the family throughout their lifetime. is a multi-disciplinaryclinical and research center whose affiliated physicians arefaculty members at ut health medical school inhouston, texas. the fetal center providescomprehensive maternal, fetal, and neonatal healthcare to pregnant women

whose unborn babies havebeen diagnosed with a birth defect or a genetic condition. located in the heart of theworld-renowned texas medical center, the fetal center atchildren's memorial hermann hospital includesaffiliated fetal, pediatric, and adult specialistswho provide a superior level of care forhigh-risk expectant mothers with complex disordersof the fetus. the fetal center and itsaffiliated physicians

offer coordinated maternal,fetal, and neonatal care by providing a full spectrumof prenatal diagnostic evaluations, fetal surgery,and follow-up care. for all conditions,the fetal center works closely withpatients to deliver the most comprehensive carefor mothers and their babies. the fetal center'saffiliated physician team aims to provide all familieswith a complete understanding of their child'scondition and prognosis

through prenatal counselingand educational materials. patients are evaluatedwith advanced fetal imaging including fetal mri andfetal echocardiography to provide the mostaccurate prenatal diagnosis. this educational video,produced by the fetal center is designed to provide anoverall understanding of spina bifida and availabletreatment options. it should be used in conjunctionwith personal evaluations and consultationswith your doctor.

patients should not basedecision making solely on the informationprovided in the video. the physicians affiliatedwith the fetal center at children's memorialhermann hospital provide medical servicesas members of ut health and the university oftexas health science center at houston.