Ans. is 'c' i.e., Inse a nasogastric tube Management of congenital diaphragmatic hernia o Earlier congenital diaphragmatic hernia was considered to be a surgical emergency. It was believed that the mass effect of herniated viscera is the major factor in cardiorespiratory compromise. o Now it is recognized that major cause of cardiorespiratory compromise is pulmonary hypeension and pulmonary hypoplasia. o So now the patient is initially resuscitated before surgery is performed. This resuscitation consists of a) Stabilization by mechanical ventilation with 100% 0, b) Nasograstric suction o Ventilation prevents the development of pulmonary hypeension and provide adequate oxygen delivery. Now days infants are ventilated by high frequency oscillation. o Nasogastric tube is used for suction to aspirate swallowed air and to prevent distension of the herniated bowel which would fuher compress the lung. o So both option 'c' & 'd' are preoperative procedures in congenital diaphragmatic hernia. The question is which should be performed fist. Remember that nasogastric suction is performed first in a case of CDH unless the patient presents with following symptoms ----> a) Cyanosis, b) Apnea, c) Respiratory disease o Here in the question the patient does not complain of any of the above symptoms so nasogastric suction should be the first priority.