Basic Obstetric POCUS

Chapter 1. Introduction

Welcome to the Basic Obstetric POCUS Course designed for the midwives in the Gulu district of Uganda!

On behalf of Well On Their Way and WPOCUS Consulting, we are pleased to present this program to help you gain knowledge and skill in performing simple point-of-care ultrasound to enhance your decision-making in caring for the women you serve.

The short acronym ‘POCUS’ is used to describe ‘point-of-care ultrasound’. It was previously known as “limited ultrasound” but renamed as ‘point-of-care’. The term was changed to eliminate the connotation that limited ultrasound was less accurate than a comprehensive exam. POCUS is not meant to replace comprehensive diagnostic imaging. POCUS focuses on specific, limited clinical questions and concerns that require quick decision-making.

Point-of-care ultrasound is within the practice scope of most women’s health providers. It enhances clinical assessment and decision-making, improving care for the women served. This initial course focuses on basic ultrasound principles, providing fundamental concepts of how ultrasound is performed safely and how to use the technology to provide the best possible image.

Why is POCUS important

The WHO (World Health Organization) has recommended that each pregnant woman have at least one ultrasound prior to 24 weeks’ gestation. Since midwives provide most of the obstetric care globally, their need for this skill is particularly urgent. Unfortunately, there are not enough sonographers or radiologists in most countries to serve the needs of all women, especially in remote areas. Many maternal/fetal conditions presenting the highest level of mortality and morbidity can be detected and mediated by POCUS. This makes the midwife a critical provider of this skill for saving lives.

In this chapter we will cover the following:

Differentiating point-of-care ultrasound from diagnostic ultrasound

Indications for women’s POCUS

Core components of POCUS

Who should provide POCUS

Standards and Guidelines for Women’s POCUS

For decades ultrasound has evolved as an integral tool for all aspects of medical care, including women’s health. It has become standard for first-line assessment in many areas of health care: in hospital emergency rooms, first-line responders like ambulance technicians, and in medical clinics. It is used by nurses, doctors, and other technicians for procedures such as locating blood vessels to improve intravenous access, as one example. Point-of-care ultrasound has become so highly integrated that it is now part of healthcare education curricula in many parts of the world

Since ultrasound is considered one of the safest modes of imaging, it has become the method of choice for evaluating pregnancy and pelvic conditions. It is also well-established that outcomes improve with use of point of care ultrasound by increasing urgent care and decreasing the waiting times for imaging. Rapid bedside assessments allow care to be expedited.

The affordability of smaller portable ultrasound machines, like hand-held units, has made bedside ultrasound assessment more accessible to low resource areas. Most portable machines allow for the transfer of images to collaborating experts in another location, which benefits providers who work in remote areas outside of a hospital or clinic setting.

How does point-of-care ultrasound benefit women’s health?

Figure 1. How does point-of-care ultrasound benefit women’s health?

Serves as integral tool for all aspects of healthcare

Is becoming standard for first-line assessment

Considered a critical skill for all healthcare providers

Considered Imaging of choice for evaluating pregnancy and women’s health

Demonstrates improved outcomes

This course by no means provides sufficient training for performing standard or diagnostic ultrasound. Courses for comprehensive OB/GYN ultrasound are designed for those who wish to become certified as a registered diagnostic sonographer

This basic course distills ultrasound concepts to essential elements needed for understanding how to capture the best quality images for rapid bedside assessment.

NOTE: Despite the limited scope of POCUS, it is imperative that learners have appropriate standardized education, basic skills training, and validated competency. It is also crucial that providers adhere to their respective scopes of practice and do not try to perform ultrasounds that are beyond their scope or training.

It is critical to have clinical backup of clinicians who are knowledgeable about interpreting ultrasound as well as obstetric backup for complications that are detected.

Do not feel overwhelmed!

Figure 2. Do Not Feel Overwhelmed!

This course was designed to introduce ultrasound concepts in a simplified format for non-sonographer providers of women’s health and novices in performing ultrasound. Learners who are new to POCUS often feel intimidated by the amount of technical and clinical training required to perform ultrasound exams. However, in this course, we have simplified many of the concepts of ultrasound properties to essential elements needed to get the most accurate images and perform this function safely.

Learning ultrasound is a process and a career-long endeavor. It is unrealistic to expect to learn everything about ultrasound (or even POCUS) in this course.

This online course is designed as an introduction to concepts, and a pre-requisite for hands-on skill training. Studies have shown that online didactic learning prior to hands-on skill training enhances the learning process during the skills sessions. Ultrasound is a technique that requires hands-on practice and ongoing learning. The end goal of POCUS education is to achieve competency and to implement review techniques to assist in ongoing improvement in skills.

This curriculum is divided into 11 chapters, each focusing on one aspect of POCUS used in obstetrics and midwifery care.

In addition to describing use of POCUS in obstetrics, there is a section reviewing basic gynecologic POCUS. It provides a basic understanding of how to scan pelvic anatomy, allowing you to better identify and assess early pregnancy maternal structures as well as fetal structures.

What to Expect

The overall activity objectives are listed below and include topics that will provide a good foundation for learning to acquire and evaluate good images in the practice of women’s health POCUS.

Each learner may move through the chapters at different speeds, depending on prior knowledge of maternal/fetal anatomy, and prior experience using ultrasound. The information is intended to be as basic as needed to learn how to perform only point-of-care ultrasound. In women’s health, these are “simple” scans that can be of great help in “seeing” things that allow a clinician make a judgement at the woman’s bedside. Learning basic point-of-care (POCUS) requires understanding of basic essential concepts.

There will be additional resources and training videos added throughout the course. There is no official textbook required, but we are including a copy of the book entitled, Ultrasound in Obstetrics and Gynecology: A Practical Approach, by Dr. Alfred Abuhamad.

This book was published as a free online guidebook for practitioners learning POCUS in obstetrics. The website for accessing this free text is:

https://www.glowm.com/resource-type/resource/textbook/title/ultrasound-in-obstetrics-and-gynecology:-a-practical-approach/resource-doc/1785

Point-of-Care Ultrasound

Point-of-care ultrasound is within the scope of most women’s health providers, and is considered an important tool for midwives. It enhances clinical assessment and decision-making, improving care for women and babies. This initial course focuses on basic ultrasound principles, providing fundamental concepts of how ultrasound is performed safely and how to use the technology to provide the best possible images.

What is POCUS?

Defining Point-of-Care

Figure 3. Definition of point-of-care ultrasound

The definition of point-of-care is this:

—Any assessment or care that is performed at the patient’s bedside

—Done to provide first-line care; avoiding unnecessary delay and accelerating care management.

The benefits of point-of-care diagnosis include expedited referral or treatment, and improved safety and quality of care.

‘Point-of-care’ pertains to other medical skillsets and testing, so the concept is not new. Point-of-care simply means that you are performing a task at the woman’s bedside, rather than transporting her to another department for testing. Point-of-care ultrasound (POCUS) is utilized in a variety of specialties in addition to women’s health.

Point-of-care ultrasound in women’s health is performed in response to a woman’s current physiological signs or symptoms, where imaging will enhance the ability to detect an abnormality. The implication is that it is performed by non-sonographers, in a clinical setting where the primary practitioner encounters the woman. Although maternal/fetal pathology is not reviewed in detail in this basic course, you will be taught ways to recognize deviation from normal and be able to distinguish between a reassuring image and one that is not reassuring, requiring consultation or referral.

In many situations (especially in your setting) a sonographer is not readily available for assessing your patient, such as in the middle of the night when complications occur. Clinical care decisions often need to be made urgently without delay. The information obtained by the ultrasound is immediate, benefiting the patient by avoiding delay of diagnosis and treatment. This care is provided by advanced practice providers (midwives, specialty nurses) in addition to physicians.

Soni, et al, states that “point-of-care ultrasound differs from comprehensive ultrasound in several aspects. POCUS exams are generally employed to detect acute, potentially life-threatening conditions where detection at the bedside expedites patient care.”

Core components of POCUS

Figure 4. Core components of POCUS

Indications (reasons) for the exam

Image Acquisition

Image Interpretation

Integration of Findings into Management of Care

Table 1. provides a list of the most common reasons for performing women’s point of care ultrasound. This overview is presented as information for all the uses of POCUS in women’s health, although this course focuses on basic obstetric applications. Women’s POCUS includes obstetric and gynecologic assessment but also extends to reproductive healthcare in general.

Table 1. Summary of uses of POCUS in women’s health

Figure 5. Variables affecting use of POCUS

The variables affecting models of practice include country-specific practice laws, or scope of practice definition of the midwifery or nursing regulatory boards. Ministries of Health are most often engaged in reviewing practice standards as well, since in many countries the nursing councils are overseen by them.

Practice location is important since it describes several things. Institutional culture determines the acceptance of non-radiology or non-physician professionals performing sonography. The location of the practice site is also important – the more remote, the more important POCUS becomes.

The patient population and disease burden determine the need for POCUS versus risking delayed conventional diagnostic scans.

The woman’s condition determines whether a POCUS is needed or whether she can wait for a more comprehensive scan. The critical nature of the patient’s condition determines the need for quick response versus risking a delayed but more systematic examination. In other words, if a woman comes in with preterm labor and is progressing rapidly, there may not be time to wait for a sonographer to arrive next morning to do the scan, or to refer her to a nearby hospital for quick evaluation.

Ultrasound interpretation skills of the consulting physician may also determine whether a midwife is able to provide a POCUS exam. For example, the practitioner may be well-trained, but the consulting physician may not feel competent in interpreting the ultrasound findings.

Existing resources such as machine availability and capabilities also determine how easily POCUS can be done. Questions to ask include, is there ready access to a machine? Is it in good working order? Is there existing power or WIFI access at the site?

Who Should Provide POCUS?

In addition to obstetric physicians, midwives, birth attendants and other obstetric providers are logical providers to do women’s POCUS since they are often in the position to expedite critical clinical management for the woman they are attending. Existing knowledge of anatomy, physiology, and OB/GYN management makes the learning curve easier.

Figure 6. Who should provide POCUS?

Despite the advantage of knowing female anatomy, the novice ultrasound learner requires a working knowledge of the science and technology of sonography (how to operate a machine and produce a meaningful image). This is all done in compliance with training guidelines and scope of practice boundaries to ensure patient safety and high-quality care.

As stated earlier, competency for safe practice is the goal of this training. Proficiency in sonography requires practice and cannot be established in a short span of training. Ongoing learning is required to keep skills current.

POCUS Standards and Guidelines

Standards are necessary since they give parameters and safeguards to determine whom and how a provider or midwives can perform OB/GYN POCUS.

Figure 7. Who defines standards and guidelines for ultrasound practice?

Groups of experts worldwide have researched ultrasound practice, developing carefully researched guidelines. These established national and international ultrasound societies and organizations describe safe ultrasound practice parameters. Performing POCUS is acceptable, allowed, and appropriate, depending on one's defined scope of practice and successful completion of a recognized training program.

These organizations define types and categories of ultrasound, based on how detailed or comprehensive the exam requires. They define HOW to perform ultrasound (for example, techniques to measure specific structures accurately and consistently).

Most guidelines also define who can perform an ultrasound, and more specifically, what type of ultrasound they may perform. For example, only perinatologists or obstetric specialists may perform and interpret comprehensive obstetric scans in some settings.

Additionally, standards offer guidelines for minimal training for competency in doing these exams.

The next figure lists some of these organizations, especially those impacting POCUS, and summarize their various contributions to the practice of ultrasound in women’s health. There are specific POCUS definitions within some of these guidelines.

Figure 8. Standards and guidelines by international societies

At the top of the list of international organizations is ISUOG, or International Society of Ultrasound in Obstetrics and Gynecology. This organization is entirely focused on the use of ultrasound in women’s health and is led by some of the most renowned OB/GYN physicians, maternal fetal medicine specialists, and radiologists in the world. Not only does this organization provide guidelines, it provides educational opportunities and seminars for an international audience.

WHO, the World Health Organization, also publishes a lengthy document establishing guidelines for use of ultrasound.

The WFUMB, World Federation of Ultrasound in Medicine and Biology, is actively involved in international promotion of OB/GYN ultrasound and is a primary funding source of research.

The ICM, or International Confederation of Midwives, provides practice standards and competencies for midwives globally. Their updated 2024 competencies include a section specifying recommendations for use of technology and ultrasound by midwives, mentioning the use of POCUS.

Almost every country or region of the world has a radiology or ultrasound professional organization providing standards and guidelines for the practice of ultrasound. These are only a sample of organizations and societies. When cross-referencing these standards, there is little difference in technical recommendations, but there are some differences in domains of practice and what levels of clinicians they consider eligible to perform ultrasound, even with training.

In the United states, the primary organizations with published standards for ultrasound performance are:

Nursing and Midwifery Standards

In addition to establishing guidelines for sonographers and physicians, nursing organizations have also recognized the need for including POCUS in nursing practice in many countries.

Nursing and midwifery organizations in North America offer practice statements recognizing POCUS within midwifery scope of care. These may serve as templates for other countries to use. The ACNM, or American College of Nurse-Midwives, developed a position statement on the use of ultrasound by midwives in 2012, and revised it in 2018 and 2023 to be in alignment with the AIUM’s practice statement including midwives and nurse practitioners. This Position Statement affirmed that it is within the scope of midwifery practice for midwives to incorporate OB/GYN sonography into the approved skillset, provided that the midwife shows evidence of following the ACNM guidelines for training and practice boundaries. The ACNM was very specific in its guidelines for educational requirements to be met before a midwife can safely perform POCUS.

The required components of POCUS education by ACNM is consistent with those of other organizations mentioned above:

-Physics and instrumentation

-Required elements and components (specific to type of exam)

-Required recognition of anatomic landmarks

-Clinical implications of normal and abnormal findings

-Indications for the exam

-Ultrasound safety

-Components of a complete ultrasound report

-Client education (explanation of results)

-Additional didactic content specific to type of exam (gyn, ob, etc)

All of this information is reviewed for you to let you know that POCUS has become almost universally accepted as an important tool for midwives, and that the standards are applicable to any setting.

WHY IS THIS INFORMATION IMPORTANT?

Policy and standards documents provide:

-- rationale and justification for midwives using this technology in your clinical setting

—basis and structure for performing POCUS

---educational and practice standards for midwives using POCUS

-- types of ultrasound appropriate for midwives, establishing safe practice boundaries

POCUS Competency

How much training and practice is required for one to become competent doing POCUS exams? Despite studies to determine this, there is little consistency in determining the exact numbers of hours of training or numbers of scans required to demonstrate competency in POCUS. One early nursing study by Stringer showed that about 12 hours of didactic training and 6-9 hours (or 20-60 supervised scans) is necessary.

However, the length and extent of training varies from person to person, depending on their prior experience and aptitude.

The AIUM published a document in 2018 recommended 30 hours of medical education credits, and at least 150 limited ob ultrasounds in the prior 36 months. This is the recommendation for advanced practice midwives and nurses in the U.S. This applies to scans that are done at a more advanced level than the basic ob scans you will be learning.

Breunig et al conducted a literature review of 893 studies and cited the consistent recommendation of performing 10-25 scans per application of POCUS to establish minimal competency. As you can see, there is wide variation in determining minimal competency requirements.

The ultimate test for competency is obtaining a certificate from a credentialed entity. Some of the international groups mentioned above are beginning to offer such certifications. POCUS certification may become necessary for licensing and regulating agencies in some areas.

The following is a diagram of the steps outlined by ISUOG to describe the pathway to quality in POCUS in ultrasound imaging and they apply to POCUS.

Figure 9. Diagram of the pathway to learning and practicing POCUS

SUMMARY

POCUS has been established as an integral tool for providers of women’s health

Definition of POCUS: in response to a woman’s current physiologic signs or symptoms. At the bedside, to evaluate for condition requiring a clinical decision.

POCUS can and should be provided by trained practitioners

POCUS exam components are well-defined

POCUS practice and training guidelines are established by national and international organizations, to ensure a standardized and consistent level of care

YOU MAY NOW TAKE THE QUIZ AND MOVE TO THE NEXT CHAPTER. YOU WILL NOT BE ABLE TO OPEN THE NEXT CHAPTER UNTIL YOU COMPLETE AND PASS THE QUIZ. YOU WILL HAVE AS MANY TRIES AS YOU NEED TO GET ALL THE ANSWERS CORRECT!

You may also visit the GUSI site and review the first section entitled, Intro to OB Essentials and POCUS. This will have 6 short videos covering the information provided in the first 4 chapters of this course.

GULU Midwives Basic Obstetric POCUS

Chapter 1. Introduction