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Discipline

: Obstetrics & Gynaecology

Sub Discipline

: Obstetrics And Gynaecology

Document Title

: Obstetrics Maternal Fetal Medicine Note

Present Pregnancy

Gestation (Weeks)

Blood Group

AABBOUnknown

Rhesus

PositiveNegativeUnknown

Anti D

Given

Gestation

TYPE OF PROCEDURE

Procedure Ordered

AMNIOCENTESIS

Date

Time Start

Time End

Indication

Instruments Used (Needle)

Others

No Of Attempts

Sample

Blood stained

Transplacental

No

Volume Obtained (Ml)

Problems

Investigations

Comments

Postoperative Evaluation

Fetal Heart Activity

Absent

AMNIOINFUSION

Date

Time Start

Time End

Indication

Instrument

Insertion Site

Method

Transplacental

No Of Attempts

Volume Infused (mls)

Solution Infused

Normal Saline

Comments

Postoperative Evaluation

Fetal Heart Activity

Absent

Findings

AMNIOREDUCTION

Date

Time Start

Time End

Indication

No Of Attempts

Sample Quality

Blood stained

Volume Drained (mls)

Comments

Postoperative Evaluation

Fetal Heart Activity

Absent

CHORIONIC VILLOUS SAMPLING

Date

Time Start

Time End

Indication

Route

Transvaginal

Sample Obtained (mls)

No Of Attempts

Comments

Postoperative Evaluation

Fetal Heart Activity

Absent

FETOSCOPIC LASER COAGULATION

Date

Time Start

Time End

Indication

Anaesthesia

Instruments Used

Fetoscope 0°

Fetoscope 30°

Bipolar forceps

Others, specify

Power Used

Port Used

Rigid port

Vascular catheter

Others, specify

Placenta

Anterior

Total number of Vascular Anastomosis

Total number of Vascular Anastomosis

Arterio - venous (donor-recipient)

Solomon Technique

No

Difficulties Encountered

None

Cloudy amniotic fluid

Bloody amniotic fluid

Bleeding

Others, specify

Diagram Of Anastomosis

Amnioinfusion Done

No

Amnioreduction Post Procedure

No

Other Procedures Done

No

Postoperative Evaluation

Fetal Heart Activity

Absent

DVP

Donor

cm

Recipient

cm

Comments

FETAL BLOOD SAMPLING

Date

Time Start

Time End

Indication

Instruments Used (Needle)

Others

Method

Transplacental

Sampling Site

Intrauterine Transfusion

No

No Of Attempts

Postoperative Evaluation

Fetal Heart Activity

Absent

Comments

INTRAUTERINE TRANSFUSION

Date

Time Start

Time End

Indication

No Of Attempts

Findings

OTHERS

Date

Time Start

Time End

Indication

No Of Attempts

Findings

PERFORMING STAFF

Performed By

SIGNATURES

Notes Component

TYPE OF PROCEDURE
AMNIOCENTESIS
AMNIOINFUSION
AMNIOREDUCTION
CHORIONIC VILLOUS SAMPLING
FETOSCOPIC LASER COAGULATION
FETAL BLOOD SAMPLING
INTRAUTERINE TRANSFUSION
OTHERS
PERFORMING STAFF
SIGNATURES

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