Obstetrics / Gynecology
Sample Name: External Cephalic Version
Description: External cephalic version. A 39-week intrauterine pregnancy with complete breech presentation.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: A 39-week intrauterine pregnancy with complete breech presentation.
POSTOPERATIVE DIAGNOSIS: A 39-week intrauterine pregnancy in vertex presentation, status post successful external cephalic version.
PROCEDURE: External cephalic version.
PROCEDURE IN DETAIL: The patient was brought to Labor and Delivery where a reactive fetal heart tracing was obtained. The patient was noted to have irregular contractions. She was given 1 dose of subcutaneous terbutaline which resolved her contraction. A bedside ultrasound was performed which revealed single intrauterine pregnancy and complete breech presentation. There was noted to be adequate fluid. Using manual pressure, the breech was manipulated in a forward roll fashion until a vertex presentation was obtained. Fetal heart tones were checked intermittently during the procedure and were noted to be reassuring. Following successful external cephalic version, the patient was placed on continuous external fetal monitoring. She was noted to have a reassuring and reactive tracing for 1 hour following the external cephalic version. She did not have regular contractions and therefore she was felt to be stable for discharge to home. She was given appropriate labor instructions.
Keywords: obstetrics / gynecology, intrauterine pregnancy, vertex presentation, complete breech presentation, external cephalic version, fetal, contractions, pregnancy, breech, intrauterine,