CHANTS guideline
Gastroschisis: Stabilisation and transfer
Gastroschisis is an emergency and is a ‘time critical transfer’, i.e. one that necessitates dispatch by the
transport team within 60 minutes of referral.
Contact CHANTS at the earliest opportunity to discuss transfer. If birth occurs outside of CHANTS operating
hours, discuss immediately with the neonatal consultant on-‐call at the University Hospital of Wales who
will advise on transfer options.
Background:
Gastroschisis is a congenital defect of the anterior abdominal wall through which abdominal contents (not
covered by a sac) herniate. This is usually intestines but can include protrusion of the liver and spleen.
Incidence of gastroschisis is around 5-6 per 10 000 births in Wales – higher than other regions in the UK.
Young maternal age and substance misuse are risk factors. Intestinal atresias are seen in up to 10-20% and
polyhydramnios may indicate these. Prematurity and growth restriction are frequent. Survival is about 90%.
Pre-‐delivery management:
• Transfer in utero to UHW (or nearest available surgical centre) where safe to do so
• Where in utero transfer not possible
o Inform CHANTS and UHW surgical team and NICU of impending delivery
o Get senior medical and nursing team assembled for delivery
o In addition to standard delivery room equipment, you will need:
§ An 8-‐10Fr nasogastric tube
§ Enteral syringes
§ Cling film and gauze to make doughnut (see below)
Delivery room management:
§ Babies with gastroschisis are very vulnerable to heat and fluid loss and extra attention should be paid
to ensuring a warm and draft free delivery room.
§ Allocate prior to delivery a person each to manage airway support, gastric tube insertion and to
support the bowel.
§ Avoid delayed cord clamping and initial skin-‐to-‐skin and take promptly to resuscitaire.
§ Baby brought to resuscitaire, placed supine and managed according to normal NLS algorithm including
the use of pulse oximetry. IF ongoing respiratory support is needed, intubation and ventilation is
preferable to CPAP / non-‐invasive support to minimise bowel distension.
§ A designated person should support the bowel with their hands, keeping the bowel midline. The bowel
should also be inspected for ischaemia – it should look pink. If it looks dusky, this suggests impaired
blood supply and the bowel should be gently manipulated in to a different position to try to improve
perfusion.
§ Insert 8-‐10 Fr gastric tube and immediately aspirate and then leave on free drainage.
§ As soon as possible, the defect needs to be secured in a doughnut and wrapped in cling film (see figure
1). This is important to protect the bowel from trauma, reduce the risk of bowel ischaemia and prevent
heat and fluid loss.
§ Once the baby is stable, they should be transferred promptly to the neonatal unit in a pre-‐warmed
incubator with regular inspection of bowel loops for ischaemia en-‐route.
CHANTS guideline May 2019 Authors: Rebecca Pockett, Ian Morris Review date: May 2022
Figure 1:
Neonatal unit admission:
§ Transfer baby to pre-‐warmed incubator and re-‐inspect the bowel (making adjustments to doughnut
where necessary but avoiding any unnecessary bowel handling). Record baseline observations.
§ Aspirate the gastric tube and ensure it is placed on free drainage. The gastric tube should be aspirated
at least hourly thereafter. Aspirates should be measured and recorded within a strict fluid balance log.
Gastric losses should be replaced ml for ml with 0.9% sodium chloride containing 10mmol of Potassium
chloride per 500mls.
§ Obtain IV access: 2 cannulas, avoiding potential long line sites where possible as these infants will
require several weeks of parenteral nutrition. Take bloods for FBC, crossmatch, blood gas, blood
culture and biochemistry. A sample of maternal blood for crossmatch should be taken ready for the
transfer.
§ Perform a general assessment of the baby to include perfusion and inspection for any associated
abnormalities. Note that insensible losses are high in babies with gastroschisis. It is often necessary to
give a 20ml/kg bolus of sodium chloride shortly after birth. Make regular assessments of perfusion and
give further boluses as necessary.
§ Administer vitamin K according to local guidelines.
§ Administer first line IV antibiotics in accordance with local guidelines.
§ Update regional surgical centre and CHANTS team.
§ Update parents, inform them of plan to transfer as soon as possible, emphasise importance of breast
feeding and early expression of breast milk in these infants.
Stabilisation for transfer:
§ This is a time critical transfer and all efforts must be made to transfer infants as soon as possible to the
nearest surgical centre.
§ The transport team will make an assessment of the airway and circulatory status of the baby.
o Where respiratory support is needed, intubation and ventilation is preferred to CPAP or High
flow to avoid gaseous bowel distension.
o Further fluid boluses with 0.9% sodium chloride may be required to maintain perfusion. It is
worth considering drawing up boluses prior to setting off.
§ Bowel should be inspected for perfusion and stability with appropriate alterations to doughnut made
where required. Gastric tube should be aspirated and left on free drainage for transfer, recording all
losses accurately.
§ Rectal temperature monitoring should be used for transfer.
§ Update receiving unit during transfer. If there are concerns regarding bowel ischaemia, the paediatric
surgical team should be contacted for advice.
References:
Public health Wales (CARIS), 2019. http://www.caris.wales.nhs.uk/musculoskeletal-system
ADHB. Neonatal surgery abdominal wall defects http://www.adhb.govt.nz/newborn/Guidelines/Surgery/SurgeryAbdominalWall.htm
CHANTS guideline May 2019 Authors: Rebecca Pockett, Ian Morris Review date: May 2022
Gastroschisis: Making a doughnut
Equipment
• Cling film
• Nappy or gauze/gamgee
• Tape
This is a clean procedure that does not need to be sterile.
Construct a roll from a standard nappy or gauze, it may be necessary to use more than one nappy
depending on the gestation and size of defect. Open out the nappy and roll length ways securing with tape.
Cover roll with cling film to secure.
Over lapping cling film is useful to tie the donut around the defect.
CHANTS guideline May 2019 Authors: Rebecca Pockett, Ian Morris Review date: May 2022
