• Defect of the backbone and spinal cord 
• MMC is the most serious type of spina bifida; spinal cord and meninges push out and create a sac in baby’s back 
• Associated with significant damage to spinal cord 
• Can leave nervous system vulnerable to life-threatening infection 

Antenatal diagnosis

• Refer to neurosurgery team 
• Offer mother appointment with neurosurgeon before the birth 

Post-delivery

Neonatal management in local unit:

• Systemic management: as per local unit guideline 
• First line antibiotics: see Infection in first 72 hours of life guideline
• Give vitamin K 
• Nurse prone/lateral, irrespective of gestation and ventilator status 
• Baseline cranial ultrasound 
• Occipital frontal circumference (OFC) daily before transfer 

Specific MMC management

• Open MMC 
  • surgical closure recommended in first 24–48 hr 
  • transfer to appropriate surgical unit ≤24 hr (providing condition stable) 
  • if flap closure required neurosurgeon to refer to plastic surgeon 
• Closed MMC 
  
  • treat as elective surgery 
• Protect exposed meninges until surgical closure performed. Immediately after delivery cover lesion with non-adherent silicone dressing e.g. Mepitel^®, followed by sodium chloride soaked gauze. Cover with cling film 
  
  • do not place gauze in direct contact with exposed meninges – can cause tearing and leaking of CSF as gauze dries out and sticks to meninges 
  • if gauze becomes dry, moisten with sodium chloride, keeping Mepitel^® in place 
  • if baby nursed in incubator, adequately soak gauze and check 4-hrly 
  • if gauze becomes soiled with faeces or urine, change immediately 
  • nurse baby prone/lateral 
  • do not dress baby – may cause injury to lesion 
• If evidence of hydrocephalus, cerebral spinal fluid (CSF) diversion will be considered at time of closure 
• Avoid contact with products containing latex; high risk (25–65%) of developing latex sensitisation and allergy 
  
  • complete red allergy band with ‘latex precautions’ and place sign above bed 
  • inform theatres of latex precautions at time of booking 
• Risk of hydrocephalus, daily monitoring of: 
  
  • OFC 
  • depth and softness of anterior fontanelle 
• Document daily on centile chart: 
  
  • head circumference 
  • weight 
• Document pre-operative administration of vitamin K and completed screening tests on neonatal checklist 

• Protect lesion from soiling and contamination 
• Nurse baby prone/lateral 
• Apply minimal tape to skin due to sensitivity to tapes, and to prevent epidermal stripping 
• Bloods for: 
  
  • FBC 
  • U&E 
  • clotting 
  • group and save 
• Ultrasound of renal system 
• MRI of head and spine at earliest opportunity as baseline (if possible pre-operatively, but do not delay surgery for imaging) 
• Consider clinical photography before and after repair 
  
  • obtain consent at time of consenting for surgery 

• Provide parents with wound care advice
• Advise first bath 7–10 days post-operatively (unless advised otherwise) 
  • if no concerns regarding wound, baby bath solution to be used 
• Neurosurgical clinical nurse specialist to provide information regarding shunt malfunction 
  
  • if no shunt present, ensure parents made aware of signs and symptoms of hydrocephalus 
• Liaise with health visiting team to: 
  
  • arrange regular OFC measurement 
  • share contact information 
  • ensure safe infant sleeping/SIDS guidelines taught 
• Arrange follow-up appointments 
  
  • neurosurgery ward clinic: 1 week post-discharge 
  • named consultant clinic: ≤6–8 weeks post-discharge 
  • urology/urodynamics: book before discharge (including ultrasound appointment) 
• Refer to community paediatrician 
• Provide parents with contact details of neurosurgical clinical nurse specialist 
  
  • clinical nurse specialist to provide copy of SHINE charity booklet, with additional team names completed 
• Detailed discharge summary made and given to parents 
• Refer to physiotherapy service