REGIONAL HEALTH DIRECTORATE OF APURIMAC

GRAU HEALTH SERVICES NETWORK

HOSPITAL SAN CAMILO DE LELIS
"YEAR OF NATIONAL INTEGRATION AND RECOGNITION OF OUR DIVERSITY".

OBSTETRICAL ULTRASOUND

Patient: _______________________________________________
Fecha: __________________________________________________

Fetus Unico ( ) Multiple ( )

Situation Longitudinal ( ) Transverse ( )
Presentation Cephalic ( ) Podalic ( )
Position Left ( ) Right ( )
Back Lateral ( ) Previous ( ) Rear ( )

Biometrics LCN ____________ mm SG ____________ mm VV ______ mm

DBP____________ mm HC ____________ mm
AC _____________ mm LF ____________ mm

Fetal Weighted: _____________ +/- 10 % gr.

Heart Rate ___________ x min
Placenta: Previous ( ) Rear ( ) Previous ( )
Grade: I() II ( ) III ( ) Thickness: _____________
mm
Amniotic fluid: ILA: __________ cm
Fetal Malformations: No ( ) Yes ( )
Circular cord: No ( ) Yes ( )
Sex: Male ( ) Female ( )
Probable delivery date: ______________

CONCLUSIONS:
__________________________________________________________

__________________________________________________________