A term newborn develops severe respiratory distress within minutes of birth. The scaphoid abdomen, absent breath sounds on the left, heart sounds displaced to the right, and a chest radiograph showing bowel loops in the left hemithorax confirm a left congenital diaphragmatic hernia. What is the immediate priority in management?

• A Endotracheal intubation with nasogastric decompression, avoiding bag-and-mask ventilation ✓
• B Immediate thoracotomy and reduction of the herniated viscera
• C Bag-and-mask ventilation to stabilise oxygenation before transfer
• D Chest tube insertion into the left hemithorax

Explanation

The lethal problem in congenital diaphragmatic hernia is pulmonary hypoplasia and persistent pulmonary hypertension, not the hernia itself. Initial care is endotracheal intubation, gentle ventilation, nasogastric decompression, and correction of acidosis, with surgery delayed until the baby is stable. Bag-and-mask ventilation must be avoided because it forces air into the stomach and intestines, expanding intrathoracic viscera and worsening compression of the lungs. Chest tube insertion is harmful because the lucency is bowel, not a pneumothorax.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.