Chapter 10: Performing the Exam

The last chapter in this course gives an overview of performing a point-of-care ultrasound in a professional and efficient manner. Preparation is essential to providing a readily available environment that is safe and private. The objective is to incorporate the principles and concepts in this course into a purpose-driven exam, based on the woman and her individual condition and needs.

The remaining courses in this series will provide detail on how to conduct specific types of POCUS exams such as gyn and obstetric exams, as well as use of types of transducers for these exams. This chapter provides general principles of how to approach the exam.

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

Prepare for the exam
- Environment
- Machine & Supplies
- Supplies
Prepare the patient for the exam
Describe ergonomics for scanning

Approach to the Women’s POCUS Exam

Step 1. Know the Indication¹

Know why the POCUS exam needs to be done. Be clear about the clinical indication and how a POCUS exam will assist in confirming or refuting a tentative diagnosis.
Knowing a patient’s history is critical for any assessment, especially for POCUS, including prior labs and exams/ultrasounds with which to compare for consistency with the POCUS findings. Consider any verbal history from another provider, or from the woman herself.
Make sure the equipment and supplies are clean and well-organized
Talk to the woman – make sure she understands why the exam is being done and what we hope to learn from the exam
- Explain the procedure and how the exam is to be done. Listen for any additional information or concerns she has about the exam. Ask her permission to have another person in attendance during the exam, such as a partner or relative.

Figure 1. Preparing for the exam.

Step 2. Prepare for the Exam^1-2

Prepare the environment.

If the POCUS exam is to be done in the patient room, have a patient-ready exam room that is:

Clean and organized
Ultrasound equipment accessible nearby
Supplies available on the ultrasound cart, or in a special container in the patient room
Quiet room with ability to dim the lights and provide some indirect lighting
Room arrangement that accommodates the ultrasound machine/equipment.
Exam table that provides hip elevation for possible transvaginal scan (either hip wedge/pillow or stirrups)
Extra pillows or wedge to prop upper body and avoid the woman from laying flat during a 3^rd trimester ob scan.
Ensure privacy by securing the entry door to avoid intrusions

Preparing the equipment

Machine Preparation includes:

Assuring the machine is turned on OR CHARGED AND READY
Assuring it is plugged into a power source. Check battery status if running off a battery
Checking to see that cords are out of the way – avoid trip hazards
Making sure the probes are secure in their cradles
Entering the patient data while patient is preparing (Include LMP)
Selecting the appropriate probe, mode, application, and preset
Selecting appropriate medium/media for archiving
- Internal hard drive of the machine
- Thermal printer
- Flash drive or portable USB storage device
- CD writer
- DICOM
  Figure 2. Console showing gel holder.

Machine Preparation includes:

Assuring the machine is turned on OR CHARGED AND READY
Assuring it is plugged into a power source. Check battery status if running off a battery
Checking to see that cords are out of the way – avoid trip hazards
Making sure the probes are secure in their cradles
Entering the patient data while patient is preparing (Include LMP)
Selecting the appropriate probe, mode, application, and preset
Selecting appropriate medium/media for archiving
- Internal hard drive of the machine
- Thermal printer
- Flash drive or portable USB storage device
- CD writer
- DICOM

Note: cloud-based archiving may not be allowed in certain jurisdictions or countries if exams cannot be HIPPA compliant or encrypted.

Prepare supplies

Preparing and arranging supplies

Provider PPE if needed: Personal mask, hand sanitizer, access to a sink
Patient drape(s) or towels, and under buttock drape/towel if needed for exam bed protection
Probe covers/sheaths
Ultrasound gel
Personal lubricant
Tissues
Dry 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 used gloves or transvaginal sheaths exposed to body fluids
Emesis basin for nausea related to supine positions during pregnancy

Figure 3. Examples of supplies used for ob/gyn POCUS exam.

Step 3. Prepare the Patient – Explanation and Consent^1,2

Talk to the woman and listen for her concerns
Explain the reason for the exam
Explain how the test will be performed and allow for questions
Advise her of possible results and how these will help her care.
Advise her to tell you if she experiences pain, nausea or dizziness during the exam
If a transvaginal scan is indicated, ask permission and respect her choice to decline
Reassure her of the potential of consultation or referral based on findings

NOTE:

-Sonographers are trained to refrain from telling a patient what is seen on a screen during the exam without consulting a clinical provider or the radiologist who will later make the final diagnosis.

-Providers who perform POCUS have more flexibility in what is said to the patient during the scan, since typically the person doing the POCUS is her provider (who will ultimately make the clinical assessment).

Patient Comfort and Privacy

Full or empty bladder depending on type of scan
If an empty bladder is needed, consider getting a urine specimen for a pregnancy test or for other required tests
Assist the woman to a comfortable position
Assist those with disabilities to the table
Provide pillows for the head, for under knees to relax the back, or to displace the uterus laterally in gravid patients
Provide adequate draping for modesty
Provide adequate hip elevation for transvaginal scan by using stirrups or pillow/wedge under the hips

Step 4. Use Good Ergonomics

The Goals of being mindful of ergonomics are to:

Improve performance and quality
Reduce body strain and prevent injuries

Common problems faced by sonographers include:

Workspace design
Eyestrain
Improper cable management (risk of tripping or damaging the cord)
Improper height of exam table or chair Improper height of monitor
Improper grip of transducer
Poor posture

Figure 4. Examples of scanning posture.

Solutions:

Stand or sit during the exam depending on the time length of the exam and the height of the exam table

Use a stool with adjustable height
Be positioned to avoid leaning over or extending arms for a prolonged time
Position the machine or bed based on right or left-handedness
Use dominant hand to scan
Right-handed scanners should have the machine on the left and the patient on the right
Left-handed scanners should have the machine on the right and the patient on the left
Elevate the machine to comfort level
Turn the machine screen to enhance view of the screen.
The screen can be turned as needed toward the patient to allow her to view as well

Step 5. Prepare for cleaning and disinfecting

As a review from the chapter on ultrasound safety, disinfecting the machine can be done in the room for low-level disinfection, preventing time used to transport to another room for this. High-level disinfection must be done in a separate “dirty utility” room

All biohazardous chemicals and materials must be appropriately labeled.

Figure 5. Wiping down the console.

As a review from the chapter on ultrasound safety, disinfecting the machine can be done in the room for low-level disinfection, preventing time used to transport to another room for this. High-level disinfection must be done in a separate “dirty utility” room

All biohazardous chemicals and materials must be appropriately labeled.

Sonographic Reasoning Process¹

Figure 6 presents a diagram demonstrating the steps for a POCUS exam, based on a first trimester exam as example.

Figure 6. First trimester exam sonography steps.

This is an example of the steps recommended by a well-known international expert in obstetric ultrasound, Dr. Alfred Abuhamad.

6-step approach to the Pregnancy Exam³

This process is an overview of the 6-step approach to the 16-36 week pregnancy exam.

Intent: provide a guide for 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

Step 1: Determine fetal presentation
Step 2: Detect fetal cardiac activity
Step 3: Identify number of fetuses in the uterus
Step 4: Locate placenta and determine position
Step 5: Estimate the amniotic fluid volume
Step 6: Perform fetal biometric measurements

SUMMARY – Performing the Exam

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

Adequate environment, machine, and supplies preparation enhances efficiency.

Being attentive to history, patient comments and complaints allow you to be more focused 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.

Foundations of Women's Point-of-Care Ultrasound

Chapter 10 Performing the Exam Overview