Obstetric ultrasound - growth and wellbeing report template
A structured obstetric ultrasound - growth and wellbeing report template used for second-trimester examination, third-trimester growth examination, fetal wellbeing assessment, multiple pregnancy examination, limited obstetric follow-up, cervical assessment. It covers 7 sections and 31 fields.
Demonstration content. Review and approve this template with your clinical lead before clinical use. Reference values shown in SonoTez are notes only and are never applied automatically.
Technique
Transabdominal obstetric ultrasound.
What to include: sections and measurements
Gestation
- Number of fetuses: singleton · twin · triplet · higher order
- Chorionicity / amnionicity (as documented)
Fetus repeatable
- Cardiac activity: present · absent · not yet assessable
- Fetal heart rate (entered) (bpm)
- Lie: longitudinal · transverse · oblique · unstable
- Presentation: cephalic · breech · transverse · oblique · variable
- Fetal movements: present · not seen during the scan
Biometry
- BPD (mm)
- HC (mm)
- AC (mm)
- FL (mm)
- EFW (g) calculated
- BPD - GA as reported
- HC - GA as reported
- AC - GA as reported
- FL - GA as reported
- Average GA as reported (with reference)
- EDD by this scan (as reported)
Placenta
- Location: anterior · posterior · fundal · lateral
- Segment: upper segment · lower segment
- Relation to internal os: clear of the os (no previa) · low-lying · covering the os
- Distance from internal os (mm)
- Maturity grade (doctor-assessed): grade 0 · grade i · grade ii · grade iii
- Other placental findings
Amniotic fluid
- Method: single deepest pocket · amniotic fluid index · subjective assessment
- Measurement (cm)
- Doctor's assessment: appears normal · appears reduced · appears increased
Cervix
- Approach: transabdominal · transvaginal · transperineal
- Cervical length (mm)
- Internal os: closed · funnelling · open
Other findings
- Other findings
Writing the impression
Answer the clinical question first, list the remaining findings in order of importance, and keep anything new out of the impression. If a structure was not fully seen, say so and give the reason. See how to write an ultrasound report for wording and certainty terms.