From the Research
To document an External Cephalic Version (ECV) procedure, begin by recording the patient's informed consent after discussing risks, benefits, and alternatives, as supported by the most recent study 1 which compared the efficacy of atosiban versus ritodrine as tocolytics in external cephalic version.
Pre-Procedure Documentation
Document pre-procedure assessments including:
- Gestational age
- Fetal position confirmed by ultrasound
- Fetal heart rate monitoring
- Maternal vital signs Note any tocolytic medications administered (such as terbutaline 0.25mg subcutaneously or nifedipine 10mg orally) to relax the uterus, as studied in 2 and 3.
Procedure Details
Detail the procedure itself by describing:
- The direction of manipulation (forward or backward somersault)
- Duration of attempts
- Number of attempts (typically limited to 2-3)
- The healthcare providers present
Post-Procedure Documentation
Document post-procedure information including:
- Final fetal position
- Post-procedure ultrasound findings
- Fetal heart rate patterns
- Any complications
- The patient's condition Include follow-up plans and instructions given to the patient about monitoring fetal movement and signs of labor or complications, as emphasized in 4 and 5.
Importance of Documentation
Thorough documentation is essential for continuity of care and medicolegal purposes, as it provides a clear record of the clinical decision-making process and the patient's response to the intervention, highlighting the need for accurate and detailed documentation as seen in the studies 2, 3, 1, 4, 5.