Chapter 8. Performing the Obstetric Exam

Welcome to the chapter on performing the obstetric exam. This chapter covers how to conduct the exam professionally and efficiently, with steps to create a safe, private environment and maximize patient time through proper preparation. The aim is to use evidence-based skills tailored to each woman's needs.

OBJECTIVES:

By the completion of this Section the participant will be able to:

1. Prepare for the exam, including environment, supplies and machinery

2. Prepare the patient for the exam

3. Describe ergonomics for scanning

4. Describe ultrasound etiquette and effective patient communication

Exam preparation

Before performing an obstetric or gynecologic exam, a clinician must understand the reason for the exam by reviewing the patient’s history, prior labs, ultrasounds, and any relevant verbal reports. All equipment and supplies must be readily available, clean and organized. Performing a POCUS exam is often an interruption in the work flow of a clinician, so having everything quickly accessible makes the exam more streamlined.¹

The woman needs to know about the purpose of the exam and the expected outcomes. It is important to describe the procedure and steps involved in the exam while taking time to listen to any questions or concerns she may have regarding the exam.

Figure 1. Illustration of basic preparation for a POCUS exam.

Preparing the environment

Have a patient-ready area that is:

Clean

Organized

Supplies easily accessed

Quiet, with ability to dim lights

Secure access to insure privacy

Figure 2. Preparing for the POCUS obstetric exam.

Preparing the equipment

Machine Preparation:

Assure the machine is turned on OR CHARGED AND READY

Assure it is plugged into a power source. Check battery status if it runs off a battery

Check to see that cords are out of the way – avoid trip hazards

Make sure the probes are secure to avoid dropping

Enter patient data and Include LMP

Select the appropriate mode, application, preset, and probe

Select appropriate medium/media for archiving

Thermal printer

Flash drive

CD writer DICOM

Figure 3, photo 1. Preparing the equipment for a POCUS exam.

Preparing supplies

Preparing for the exam includes:

Preparing and arranging the supplies needed:

Figure 4. Preparing supplies for the POCUS exam.

Personal mask (for COVID concerns) Hand sanitizer

Patient drape(s) Probes

Probe covers/sheaths

Ultrasound gel

Personal lubricant

Tissues

Cloth for wiping probe after exam

Towel or cloth for wrapping the used TV probe for transport to dirty utility room

Disinfecting wipes

Biohazard bag to dispose of TV sheaths exposed to body fluids

Emesis basin

Preparing the patient

Talk to the woman and listen for her concerns; explain reason for the exam

Explain how the test will be performed; allow for questions

Inform her about the objectives of the examination and how the results may assist in planning her care.

Advise her to tell you if she experiences nausea or dizziness during the exam

If transvaginal scan is indicated, ask permission and respect her choice to decline

Figure 5. Preparing the patient for the POCUS exam; consent and explanation.

Figure 6. Preparing for patient comfort and privacy.

Ergonomics

Figure 7. Ergonomic considerations for scanning.

The Goals of being mindful of ergonomics are to:

--Improve performance and quality

--Reduce body strain and prevent injuries – practice good posture, proper grip of the transducer, adapt bed or chair to accommodate scanning position

-- Minimize eyestrain – raise screen to appropriate eye-level

--Manage cord draping to avoid tripping

Figure 7. Goals for scanning ergonomics.

Figure 8. Scanning ergonomics considerations.

Poor ergonomics can create strain on muscles, so stand or sit during the exam when possible

Position yourself to prevent prolonged reaching or leaning. Place the machine or bed according to your dominant hand. Right-handed users should keep the machine on the patient's left side.

Left-handed scanners should position the machine on the right of the patient.

Elevate the monitor to to a comfortable level

Turn the monitor toward you to improve visualization and get accurate measurements

The screen can be angled for the woman or family can see also if it does not compromise the scanner’s view.

Visitors during the scan

Visitor policies depend on facility guidelines. Always ask the woman if she is comfortable with others present, especially during a transvaginal ultrasound. Family members are often welcome for obstetric scans unless complications arise, and some women want children to see the baby. If children attend, another adult should supervise them, so the clinician is able to focus on the exam.

Figure 9. Visitors during the POCUS exam.

Preparing for cleaning and disinfection

Disinfecting the machine can be done in the room for low-level disinfection. High-level disinfection should be done in a separate “dirty utility” room.

All biohazardous chemicals and materials must be appropriately contained and labeled, and kept away from patients.

Figure 10. Preparation for cleaning and disinfecting equipment.

A pictorial step-by-step approach to a standard obstetric exam was published by Bethune et al and is referenced.²

Six step Approach to the Pregnancy Exam

Abuhamad et al. Standardized six-step approach to the performance of the focused basic exam³

This exam can be performed between 18- and 36-weeks’ gestation

This list is an overview of the 6-step approach to the pregnancy exam.

Figure 11. Six step approach to pregnancy ultrasound, Abuhamad.

The intent is to use a simple, brief, standardized approach for performing POCUS in pregnancy, particularly for use in low-resource areas to expedite care when a more advanced ultrasound is unavailable

Communicating information to the woman and her family

Approach for Informing women and families re: unexpected findings on ultrasound⁴

Ref: Walk with Me

A recent bulletin offers general advice for obstetric sonographers on communicating findings of life-altering or life-threatening fetal conditions. Patients often sense abnormalities through silence or body language of the provider during the scan, or by seeing an obvious abnormality on the screen (such as absence of a fetal heartbeat). Ref Walk with me

Examples of how to start the conversation:

--"I need to talk to you about how your baby is doing; I am seeing some things on the scan that have me concerned. I am going to get another person (or doctor) to come and look with me”.

“I am seeing some things that are concerning – I know this has to be upsetting to you.

“I don’t have any answers to questions you have at this time, but hold on for a few minutes while I continue with the scan to get more images. I want to be as thorough as possible to confirm what we are seeing”

What NOT to say

--”I will get the doctor to take a look at your images”

--staying silent or leaving the room without an explanation

--phrases that minimize the distress:

--“at least” … “it was early”, or “you can try again”, or “you have other children”

--“there’s a reason for this”, or “it just wasn’t meant to be”, or “it may be for the best”

Examples of next steps:

Figure 12. Principles for communicating difficult findings on ultrasound.

Documentation

In the Foundations course of this series, a chapter was dedicated to describing correct documentation. The POCUS exam does not end when the patient leaves the facility. Documentation and communication remains as a critical piece to complete the study.

Often, in the case of POCUS exams, as described at the beginning of this chapter, the exam is an interruption in the practitioner’s typical workflow. Because of this, it is easy to neglect proper image archiving and documentation of findings. Nomura et al developed a table to define documentation deficits often seen in POCUS reporting.

This table summarizes these deficits and also serves to provide a template for quality assurance review.¹

Term	Definition
Incomplete study, missing operator	Study does not contain information on who performed the exam
Incomplete study, missing documentation	Study does not have a complete interpretation report
Incomplete study, missing images	Study does not have complete images
Incomplete study, missing patient identifiers	Study does not contain patient identifiers
“Phantom scan”	Study is not documented in the medical record or have archived images; when audited it does not exist. It is inadequate to write a simple notation in the record summarizing the exam

Table 1. Deficits in proper documentation of POCUS findings.

SUMMARY

In summary,

Conducting the ultrasound exam should be done in an efficient and professional manner.

Adequate environment, machine, and supply preparation enhances efficiency.

Being attentive to history, patient comments and complaints allows for greater focus in your exam.

Room turn-over and patient flow are maximized with adequate preparation.

Knowing your machine allows for efficient capture of quality images.

Attentiveness to ergonomics prevents unwanted strain on the sonographer.

Adopting recommendations for revealing unexpected news of a fetal abnormality provides greater comfort for women and their families.

Women's Point-of-Care Ultrasound: Second and Third Trimester

Performing the OB Exam