Chapter 1. Introduction

Women’s Point of Care Ultrasound

Essential Concepts Made Clear

Introductory Comments and Course Review

Point-of-care ultrasound is within the 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 images.

In the Foundations Course, we will cover the following:

Differentiating point-of-care ultrasound from diagnostic ultrasound
Core components of POCUS
Indications for women’s POCUS
Who should provide POCUS
Variables affecting the use of POCUS
Standards and Guidelines for Women’s POCUS
- International
- American
- Nursing and Midwifery, including ultrasound education components
Competency demonstration
Quality in POCUS imaging and guidelines

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 most healthcare education curricula.

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 ultrasound¹ ; waiting times for imaging are decreased and rapid 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 remote areas. Most 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?

Integral tool for all aspects of healthcare
Becoming standard for first-line assessment
Considered a critical skill for all healthcare providers
Imaging of choice for evaluating pregnancy and women’s health
Demonstrates improved outcomes¹
Increased access to affordable hand-held units

Point-of-care ultrasound (POCUS) education is not intended to prepare one as a professional sonographer or to perform detailed or diagnostic exams. POCUS training is designed to provide the practitioner basic skills for conducting a limited exam. It distills ultrasound concepts to essential elements needed for understanding how to optimize images for rapid bedside assessment.

NOTE: Despite the limited scope of POCUS, it is still imperative that learners have appropriate learning, basic skills training, and validated competency. It is also imperative that providers adhere to their respective scopes of practice.

Do not feel overwhelmed!

This course series 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 series, concepts of physics and instrumentation learned by diagnostic sonographers have been reduced to a minimal level sufficient to achieve quality limited ultrasound assessments.

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 series. Essential topics are streamlined to create the foundation needed to practice safely.

This curriculum is designed as a pre-requisite for hands-on skill training. Ultrasound is a technique that requires hands-on practice and ongoing learning. The end goal of POCUS education is certification of competency. Certification processes will be presented in the later course material. during the final course of the series.

This curriculum is divided into 4 separate activities, with each activity focusing on one area of women’s health. Each activity is subdivided into chapters.

The four activities are:

I. Foundations

II. GYN POCUS

III. First Trimester POCUS

IV. Second/Third Trimester POCUS

These four activities can be studied separately or as an entire curriculum package. For the best results, start with Foundations, then select which of the other courses that best meet learning needs and practice scopes. Taking the GYN course is helpful even if your practice scope includes only obstetrics; there is significant overlap with pelvic anatomy and First Trimester POCUS.

Is eLearning as effective as in-person training?

Hempel² concluded e-learning exclusively based on clinical cases is an effective method of education in preparation for hands-on sessions and can reduce attendance time in ultrasound courses.

What to Expect

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

Each learner will move through the chapters at different speeds, depending on prior knowledge of 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 help 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 complementary resources added to each chapter. Some of these include links to instructional videos that will help increase your understanding.

NOTE: This course does NOT provide 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.

Chapter 1. Introduction

Point-of-care ultrasound is within the 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 images.

Differentiating point-of-care ultrasound from diagnostic ultrasound
Core components of POCUS
Indications for women’s POCUS
Who should provide POCUS
Variables affecting the use of POCUS
Standards and Guidelines for Women’s POCUS
- International
- American
- Nursing and Midwifery, including ultrasound education components
Competency demonstration
Quality in POCUS imaging and guidelines

What is POCUS?

Defining Point-of-Care

The definition of point-of-care is this: assessment or care that is performed immediately, at the patient’s bedside, 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.³

‘Point-of-care’ pertains to other medical skillsets and testing, so the concept is not new. Point-of-care ultrasound (POCUS) is utilized in a variety of specialties in addition to women’s health and ob/gyn. All healthcare practitioners provide bedside assessment (point-of-care) – nurses, midwives, physicians, clinical officers, nurse practitioners, and physician's assistants. Even first responders have been trained to provide point-of-care ultrasound evaluation.

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.

In many situations a sonographer is not readily available, such as in the middle of the night when complications occur, and care decisions need to be made urgently. The information obtained by the ultrasound is immediate, benefitting the patient by avoiding delay of diagnosis and treatment. Much of the time this care is provided by advanced practice providers (midwives, specialty nurses) in addition to physicians.

Sidebar 1. The purpose of POCUS in women’s health.

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

Soni et al ⁴ 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 POCUS⁵

Indications
Image Acquisition
Image Interpretation
Integration of Findings into Management of Care

Indications for Women's POCUS

Table 1. provides a list of the most common reasons for performing women’s point of care ultrasound. It does not include every possible indication, but it gives an overview of the types of situations for which POCUS can be of benefit. Women’s POCUS includes obstetric and gynecologic assessment, but also extends to reproductive healthcare in general. This course focuses on basic obstetric and gynecologic applications. Subsequent courses will add intermediate and advanced concepts to include additional common gyn and reproductive medicine exams.

Table 1. Indications for Women’s POCUS⁶

Variables Affecting Use of POCUS

The variables affecting models of practice include country-specific practice laws, or scope of practice definition of the medical specialty.

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 conventional diagnostic waiting times.

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.

Skill of the performing provider and skill of the consulting physician may determine whether a provider is allowed to do POCUS exams – 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?⁷

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. WHO (World Health Organization) has recommended that each pregnant woman have at least one ultrasound prior to 24 weeks’ gestation.⁸ Since midwives provide most of the obstetric care globally, their need for this skill is particularly urgent.

But obstetric clinicians require an additional skill-set specific to ultrasonography. POCUS course learning is intended to provide basic knowledge and skills for beginning safe practice. Proficiency in sonography requires practice and cannot be established in a short span of training.

Despite the advantage of awareness of 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.

Sidebar 2. Expanding use of POCUS by medical specialty and decade⁴

POCUS Standards and Guidelines

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. It is important to know if performing POCUS is acceptable, allowed, and appropriate, depending on one's defined scope of practice.

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, there are recommendations that only perinatologists or obstetric specialists may perform and interpret comprehensive obstetric scans). Additionally, they offer guidelines for minimal training for competency in doing these exams.

Sidebar 3. Standards and Guidelines: International Organizations.

Sidebar 2. 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.

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 also 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. Intergrowth-21 is a division of WHO that has conducted research on ethnic variations in fetal growth standards. Fetal growth will be reviewed in greater detail in the 2^nd and 3^rd trimester course

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 competencies include a section specifying recommendations for use of technology and ultrasound by midwives.

The EFSUMB (European Federation for Ultrasound in Medicine and Biology) and ASUM (Australasian Society for Ultrasound in Medicine) are other organizations providing similar guidelines specific to their regions.

Almost every country or region of the world has a radiology or ultrasound professional organization providing standards and guidelines for the practice of ultrasound. This is an example of just some of these 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.

Sidebar 3. Additional international ultrasound societies and organizations

United States Standards

In the United States, the primary groups that publish standards and guidelines are described below. Some of them publish individual guidelines; some have joint guidelines for practice (such as AIUM and ACOG) (see Sidebar 4)

Sidebar 4. Standards and Guidelines: American Organizations

AIUM,or the American Institute of Ultrasound in Medicine, is the premier U.S. organization determining standards of education and practice for ultrasound in the United States. It is a body that credentials the safe practice of ultrasound in medical facilities. AIUM published a document establishing training guidelines for non-physician women’ health care providers.

Inteleos is an organization providing credentialing mechanisms for a variety of health professionals for several international regions in addition to the United States. It is the parent company of ARDMS. In addition to providing credentialing for most all medical sonographers in the U.S., it has created a testing platform for POCUS specialties, including obstetrics.

ARDMS, or the American Registry for Diagnostic Medical Sonography, is a subsidiary of Inteleos and has divisions for credentialing and certifying individual providers in all specialties of ultrasound, including abdomen, physics and instrumentation, abdomen echocardiography, fetal echo, MSK (musculoskeletal) and other areas.

SDMS, or the Society for Diagnostic Medical Sonography, is a group that supports the practice of ultrasound by promoting ultrasound principles and guidelines, as well as offering many online educational resources.

Other physician organizations have developed their own set of standards and protocols related to POCUS. ACOG⁹ (American College of Obstetrics and Gynecology) and ACEP¹⁰ (American College of Emergency Physicians) are two examples. The American Academy of Family Physicians (AAFP¹¹) has also established guidelines for types of POCUS performed by family doctors.

Nursing and Midwifery Standards

The previous organizations have developed guidelines for sonographers and physicians, but nursing organizations have also recognized the need for including POCUS in nursing practice.

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 in its list of approved providers of ultrasound.¹² This Position Statement (Figure 1.) 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 show evidence of following the ACNM guidelines for training and practice boundaries.

Hospitals may still require specific credentialing for allowing midwives and other advanced practice nurses to have privileges for POCUS in their facilities, depending on the radiology organization accrediting their radiology/sonography services. AIUM and ACR, American College of Radiology, are the primary organizations that monitor the practice of ultrasound in hospital facilities in the United States.

Although it is suggested that midwives obtain the ARDMS certificate for Midwifery POCUS, midwives and other advanced practice nurses (APRNs) may still provide POCUS exams if allowed in their local jurisdiction as a recognized practice. Currently, a midwife or APRN is eligible for financial reimbursement for ultrasound if he/she is an established billing provider. This may not be the case for settings in other countries, where midwives or nurses function in a different health care structure.

The ACNM collaborates with ARDMS/Inteleos to maintain a midwife ultrasound certificate program for those midwives seeking additional validation of point of care ultrasound competency.

Figure 1. is a copy of the first page of the 2018 ACNM Position Statement on Ultrasound in Midwifery Practice.

^{Figure 1.}^{American College of Nurse-Midwives Position Statement on ultrasound in midwifery practice, 2018, Revised 2023.}

Ultrasound Education Components

Within the above document ACNM specifies the required components of POCUS Education, which is consistent with those of other organizations:¹²

Physics and instrumentation
Required elements and components (specific to type of exam)
Required anatomic landmarks identified by AIUM
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)

POCUS Competency

There is little consistency in determining the exact numbers of hours of training or numbers of scans required to demonstrate competency in performing point of care ultrasound. One early nursing study by Stringer et al ¹³ 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, as well as basic knowledge of maternal and fetal anatomy. The AIUM published a document in 2018¹⁴ delineating recommendations for training requirements for advanced practice providers (to include nurse-midwives, nurse practitioners, and physician assistants). Their standards recommended 30 hours of AMA PRA Category I credits (or comparable certification from the respective certification boards) in addition to documentation of involvement with at least 150 limited ob ultrasounds in the prior 36 months. Additionally, they recommended 15 hours of additional CME every 3-year cycle for continued education in ultrasound. Breunig¹⁵conducted a literature review of 893 studies consistently concluding on the recommendation of 10-25 scans per application of POCUS. ^16,17However, modes of validation were found to differ among the studies.

Sidebar 5. POCUS Competency.^13-17

There have also been studies to determine if use of simulation was an adequate substitute for live scanning, and the consensus is that use of simulation shortens learning time.^18,19 There is still some disagreement among experts when it comes to specific numbers, since the learning curve varies by individual learner.

Domains of competency were outlined by Kumar et al in 2019:⁴
Acquisition of knowledge
Application of obtained knowledge
Demonstration of technical competence
Integration into clinical practice
Re-certification

Figure 2. Scoring system for POCUS competency evaluation²⁰

Competency is also monitored by mechanisms providing ongoing quality and high standards of care. When publishing guidelines specific to obstetric ultrasound, ISUOG developed a chart to describe the pathway to obtain quality practice in ultrasound (sidebar 6).²¹ These components included: guidelines for practice, a solid curriculum, establishing competency, clinical simulation, accreditation for the educational program, and continuing education (since new knowledge allows guidelines to be updated). This is another list of some additional organizations and societies with guidelines and standards. Many countries have their own guidelines for the use of ultrasound.

SIDEBAR 6. ISUOG pathway for quality practice in ultrasound.²¹

In 2015 a task force^21,22 to determine how to develop a curriculum outline based on consensus of experts. Their target audience for learning included ob/gyn physicians, radiology residents, sonography residents, and other practitioners (midwives, nurses). Two primary curriculum goals were established: cognitive learning, and clinical competency. These general goals are the aim of this course. Each of the chapters in this course series will successively build upon the learning of the previous sections, and will include specifics for performing competently and safely.

Introduction 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 PROCEED TO THE NEXT CHAPTER. THE NEXT CHAPTER AND ALL CHAPTERS FOLLOWING WILL HAVE A SHORT QUIZ AT THE END OF THE CHAPTER. YOU MUST MAKE 100% ON THE QUIZ TO MOVE TO THE NEXT CHAPTER, HOWEVER YOU WILL HAVE AS MANY TIMES AS NEEDED TO COMPLETE THE QUIZ.

Foundations of Women's Point-of-Care Ultrasound

Introduction: Women’s Point of Care Ultrasound Foundations