From 2008, the RCOG curriculum requires all Speciality Trainees to acquire ultrasound scanning skills in early pregnancy assessment and fetal biometry (basic). The basic modules should be completed within the next 2 years by those entering the training grade in August 2008 and, as soon as possible by all those who have not already done so.

West Midlands Basic Pratical Training -***** entry closed *******

From 1998 onwards the West Midlands has developed a 13 session practical program for Specialist Trainees in basic obstetric ultrasound. It forms part of the Specialist Registrars logbook nationally. To date (end 2007) 204 trainees have completed the practical part of the course.

Aims

1.    To allow safe clinical practice in emergency obstetrics:

• To confidently identify an intra-uterine death at 20 weeks gestation or more within 2 minutes of scanning.
• To confidently identify the presentation of the fetus at 20 weeks gestation or more.

2.    To introduce specialist obstetricians to the possible uses of ultrasound scanning in pregnancy care.

3.    To give fundamental training in the safe use of ultrasound scanning equipment.

Methods

Specialist Registrars will be allocated to a training place at a recognised training unit. The training will involve one session a week for 13 weeks in the ultrasound department with a designated tutor, and a theoretical course which will be organised and run by the tutors.

Practical training

The specialist registrar will be given a start date and a finish date for training. Their attendance will be recorded in a logbook together with the cases which they have seen. They will need to be released for this training and must have no other responsibility, bleeps will need to be held by colleagues. Their consultant will be informed in writing of the training programme requirements and training will not be offered to registrars who cannot be released for some reason.

Skills

The practical skills to be acquired during this programmes are:

1.   Patient related skills

• Correct patient identification
• Explanation of the procedure
• Dealing with questions about the scan
• Positioning the patient
• Patient comfort and dignity
• Patient disposal

2. Machine related skills

• Turn machine on
• Select appropriate transducer
• Understand and use the following:
  • Gain
  • Focus
  • Zoom
  • Scroll
  • Time gain control
• Clear data stored in machine
• Insert patient ID data
• Make comments on the screen
• Create hard copy images
• Clean and deal with transducer
• Turn off machine

3.   Image related skills

• Demonstrate the orientation of the images obtained
• Show the uterus, cervix, vagina, pouch of Douglas, bowel
• Show fetal heart activity, fetal movements
• Describe presentation of the fetus in words
• Show placental site
• Show liquor
• Understand and demonstrate
  • Reverberation
  • Acoustic shadowing
• Create images for the measurement of:
  • Crown rump length
  • Biparietal diameter
  • Head circumference
  • Abdominal circumference

4.   Ultrasound related practical skills

• Observe a minimum of 2 invasive procedures (amniocentesis, CVS or FBS)
• Clinical competency in obstetric ultrasound
• Transabdominal USS

Level 1:            Can understand

Level 2:            Can request appropriately

Level 3:            Can do with constant supervision

Level 4:            Can do with distant supervision

Level 5:            Can do independently

Structure of practical tuition

Week 1 - 3

The tutor will explain the standards required in the following 3 areas:

Week 1: Patient related skills

Week 2: Machine related skills

Week 3: Image related skills

Following explanation the tutor will demonstrate each of these skills during ultrasound examinations.

Week 4 - 6

The tutor will demonstrate and supervise the trainee paying particular attention to the skills required

Weeks 7 to 12

The tutor will supervise the trainee paying particular attention to the creation of images in the following areas:

Week 13

Assessment

A minimum of 10 supervised ultrasound sessions must be attended in full by the trainee. If the number of practical sessions attended falls below this level additional training will be required before taking the assessment.

Log-book

Each trainee will have a small pocket-sized logbook of ultrasound examinations observed or performed. The outline for this will be:

• Start date / finish date
• First trimester
• Second trimester
• Third trimester
• space for 4 images to be stored

Assessment

A structured assessment is undertaken on the final session of training which tests the skills which the trainee should have mastered.

Teaching package

The teaching of obstetric ultrasound is essentially a hands on exercise, but certain teaching aids may be helpful. The following are available in each teaching department:

1. Doll & Pelvis.
2. Sheet on orientation
3. Sheets with important findings on early pregnancy scans
4. Sheet with important findings on late pregnancy scans
5. Knobology sheet of terminology / definitions etc.

Orientation

Orientation is absolutely fundamental to the interpretation of ultrasound. The linear transducer produces a representation on screen of the 2 dimensional cut under the transducer.

To make the interpretation as simple as possible it is recommended that the image created on the screen is the same way round as in real life. I.e. Left is left and right is right. To ensure this every time you scan following this simple procedure.

Before putting the transducer on the patient put a finger or thumb at one end of the transducer and make sure the image is correctly orientated. If not either turn the transducer round, or invert the image on the screen. Many ultrasound transducers have a notch, or groove on one end of the probe to enable you to maintain orientation. This becomes second nature to experienced sonographers, but if you get confused go back to basics, and run your finger under the transducer to re-orientate yourself.

How is the baby lying?

Terminology

Lie = The relationship of the long axis of the fetus to the mother.

• Either longitudinal, transverse or oblique

Presentation = The part of the fetus which is pointing towards the pelvis, and therefore the part which would be born first if the woman went into labour.

• Either cephalic, breech, shoulder, back, arm etc.

Position = The relationship between the presenting part and the mothers pelvis.

• For cephalic presentations either occipito-anterior (OA), occipito-lateral or occipito-posterior (OP).
• For breech presentations Sacro-anterior, lateral or posterior.

To define the lie you need to find the head, and then the long axis of the spine. While you are moving the ultrasound transducer around think what is on the screen. Make a mental picture of this fetus, there is no trick, just look at the screen and put together in your mind all the images into a 3 dimensional map. Once you have established how the baby is lying you can keep going back to the places you want to be, to see what you need to see. As soon as you put the transducer on the patient you are being given information about the lie, presentation and position of the fetus, look at the screen to show you where you are going next.

Scanning is a bit like driving, you need to be able to move your hand into different positions without looking at where it is. This is a skill which comes with time, and must be mastered. If you need to continually look at the probe to see which way it is pointing you will not be able to scan efficiently.

A practical exercise in orientation

• Place transducer transversely on the abdomen.
• Look at the screen and describe what you see.
• Angle the probe down into the pelvis, and slid if necessary so that the presenting part is on the screen. What is it? Which way is it facing?
• Think where the spine it most likely to be.
• Move the transducer to lie longitudinally over the fetal spine.
• Run the transducer down the spine from the neck to the sacrum keeping the spine longitudinal all the time. You now know how the fetus is lying

Early pregnancy scanning

• Ask your trainee to do the following:
• Ensure room is ready to receive patient
• Ensure machine is ready. Clear data from previous scans
• Fetch patient, making sure they check ID in some way (address or DoB)
• Welcome patient into room
• Offer explanation / verbal consent
• Position patient correctly
• Use transducer correctly
• Show you / patient the uterus and look outside for any gross pathology
• Show you / patient the pregnancy
• Show you / patient the fetal heart
• Move slowly across the pregnancy to assess how many fetuses
• Show you fetal movement, head & legs.
• Comment on liquor
• Show you placental site
• Tell patient what has been found
• If bladder full (you should know from the scan) tell patient where to find toilet
• Tell her what to do next
• Write / type a report.

Late pregnancy scanning

• Ensure room is ready to receive patient
• Ensure machine is ready. Clear data from previous scans
• Fetch patient, making sure they check ID in some way (address or DoB)
• Welcome patient into room
• Offer explanation / verbal consent
• Position patient correctly
• Use transducer correctly
• Show what is presenting
• Go quickly from this to the fetal heart and show to patient
• Show longitudinal view of the spine
• Describe the lie and presentation
• Be able to show you on request head, fetal heart, spine, legs, placental site
• Show and describe the liquor volume
• Show umbilical cord in a way which would allow Doppler studies to be performed if required. Keep static on the screen.
• Make adjustments to the magnification, gain, focus & TGC as required

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