Laudário Report templates Obstetric

Second and third trimester obstetric ultrasound report template

The routine second and third trimester obstetric scan follows growth, fluid and placenta. What matters most in the report is the weight percentile, calculated with the first-trimester gestational age.

Normal template

OBSTETRIC ULTRASOUND

FINDINGS:

Single fetus in [cephalic/breech] presentation, spine on the [right/left].

Cardiac activity present and rhythmic, with a rate of [x] bpm. Fetal movements present.

Biometry: BPD [x] mm; HC [x] mm; AC [x] mm; FL [x] mm.

Estimated fetal weight (Hadlock): [x] g, [x] percentile for gestational age.

[Anterior/posterior] placenta, [x] mm from the internal cervical os.

Normal amniotic fluid volume (deepest vertical pocket of [x] cm).

Three-vessel umbilical cord.

IMPRESSION:

Single pregnancy with a live fetus, [x] weeks and [x] days by first-trimester dating.

Appropriate fetal growth ([x] percentile).

Example: small-for-gestational-age fetus

FINDINGS:

Estimated fetal weight of 1.820 g, 4th percentile for 34 weeks.

Normal amniotic fluid volume.

IMPRESSION:

Small-for-gestational-age fetus (4th percentile).

RECOMMENDATIONS:

Complementary obstetric Doppler (umbilical artery, middle cerebral artery and cerebroplacental ratio).

Fields in brackets are filled in from the exam. The template is a starting point: the report must reflect what was seen and your practice's guidelines.

Frequently asked questions

Which fetal weight formula should I use?

The most widely used is Hadlock with four parameters (BPD, HC, AC and FL). What matters is stating the formula and the percentile by the chart adopted by the practice.

Does placental grade need to be in the report?

It can be mentioned, but it has little clinical value. What matters is the location and the distance to the internal os.

Other report templates

Obstetric scan at 5, 6 and 7 weeks Obstetric scan at 8, 9 and 10 weeks Obstetric scan at 11 to 14 weeks Obstetric scan at 15 to 20 weeks Obstetric scan at 21 to 27 weeks Early obstetric (5 to 10 weeks) 1st trimester anatomy scan 2nd trimester anatomy scan Complete abdomen Transvaginal pelvic Thyroid Breast Kidneys and urinary tract Lower limb venous Doppler

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