2nd and 3rd Trimester OB Protocol

Placenta Comp Images- Heart Rate, Uterine Cervix , Ovaries, Adnexa, Placenta, and Fluid Structure/ Order Scan Plane Label NO IMAGE-SCAN THROUGH Landmarks Identified Begin at cervix, move superiorly out of uterine fundus o Identify the fetus within the uterus o Identify number of fetuses o Identify fetal lie o Determine the right and left sides of the fetus Fetal heart and chest o Enlarge image of heart and document heart rate with M-mode or Spectral Doppler Fetal heart and chest o Enlarge image of heart and document heart rate with a cine-loop Vaginal Canal Cervix Amniotic Sac Vaginal Canal Cervix Amniotic Sac Measure Cervical Length o External os to internal os Document presenting fetal structure Cervix o Indicate Breech or Vertex in annotation RT Adnexa include ovary if possible LT Adnexa include ovary if possible Placenta closest to Cervix Retroplacental complex Placenta Mid- include cord insertion Retroplacental complex Placenta- superior portion Retroplacental complex Measure largest vertical pocket clear of fetal components from Anterior to Posterior Measure largest vertical pocket clear of fetal components from Anterior to Posterior Measure largest vertical pocket clear of fetal components from Anterior to Posterior Measure largest vertical pocket clear of fetal components from Anterior to Posterior Pocket Protocol Reference Page

TX Uterus/ Fetus

TX

HEART RATE

TX

HEART RATE

Uterine Cervix

Sagittal

CERVIX ML

Sagittal

CERVIX ML

Sagittal

FETAL LIE

Adnexa

Sagittal Sagittal Sagittal

Placenta

Sagittal Sagittal

Amniotic Fluid Index (volume) Q1+Q2+Q3 +Q4= AFI *Structures seen in each pocket will vary

Sagittal Sagittal Sagittal Sagittal

ADNEXA SAG RT ADNEXA SAG LT PLACENTA SAG INF PLACENTA SAG MID PLACENTA SAG SUP Q1 Q2 Q3

423 423 550 549 548 596

Q4

2nd and 3rd Trimester OB Protocol

Fetal Measurements Structure/ Order Scan Plane Label Fetal Measurements BPD Landmarks Identified Pocket Protocol Ref. Page 575

HC

Trans Axial CEREBELLUM

CISTERNA MAGNA

NUCHAL FOLD

Abdomen TX

AC

Long Bone

FL

Long Bone HL

Cavum septum pellucidum, IHF, Thalami and Parietal bones Measurement technique Place calipers on the outside of the closet parietal bone to the inside of the farthest parietal bone Cavum septum pellucidum, IHF, Thalami and Parietal bones Measurement technique o Place calipers outside to outside of the parietal bones o Open the calipers with an ellipse that surrounds the fetal skull IHF, Cerebral Peduncles, Cerebellum, Cisterna Magna, and Nuchal Fold Measurement technique o Place calipers on the outside of the lateral wall to the outside of the opposite lateral wall IHF, Cerebral Peduncles, Cerebellum, Cisterna Magna, and Nuchal Fold Measurement technique o Place calipers at the level of the mid posterior wall of the cerebellum to the inside of occipital bone IHF, Cerebral Peduncles, Cerebellum, Cisterna Magna, and Nuchal Fold Measurement technique o Place calipers at the level of the mid posterior wall of the cerebellum from the outside of occiptal bone to outside skin line Umbilical vein/portal vein junction 3 points of the spine Symmetrical ribs Measurement technique o Place calipers on outside of skin line directly behind spine and in front of abdomen. o Open calipers to form an ellipse around abdomen including the skin line Femur bone with distal or end shadowing Measurement technique o Place calipers from end to end on the femur Do not include epiphysis point o Calipers should dissect the middle of the bone Humerus bone with distal or end shadowing Measurement technique o Place calipers from end to end on the humerus-Do not include epiphysis point o Calipers should dissect the middle of the bone

579

576

576 & 577

578

582

583

584

2nd and 3rd Trimester OB Protocol

Fetal Head and Face Structures Organ/ Order Scan Plane Fetal Head Coronal Fetal Head Fetal Head Transaxial VENTRICLES (indicate RT & LT) Label CHP Landmarks Identified IHF Choroid Plexus within ventricle o Try to get both in one image, if not do separately (in axial plane) IHF Ventricles Pocket Protocol Reference Page 580

581 w/o measurement

VENTRICLES (indicate RT & LT)

IHF Ventricle Measurement Technique o Posterior ventricle o Measure internally lateral to medial at glomus Orbits Mandible Orbits Echogenic lens (can be in transaxial plane) Nostrils Upper lip Forehead, nose, extended chin and neck

581

Fetal Face

Face Coronal

FACE

LENS

NOSE AND LIPS

590

Face Midline Sagittal

PROFILE

589

2nd and 3rd Trimester OB Protocol

Fetal Thorax, Abdomen and Pelvis Structures Organ/ Order Scan Plane Label Transverse CORD RT lung Diaphragm Liver LT lung Diaphragm Stomach Stomach Transverse spine Transverse spine Right kidney Left kidney Left Sagittal Kidney (can be taken in coronal) Measurement technique o Superior to inferior border Left Sagittal Kidney (can be taken in coronal) Measurement technique o Superior to inferior border Transverse spine Umbilical cord insertion into abdomen Abdominal skin line Umbilical cord projecting from abdomen Free floating loop of umbilical cord demonstrating 3VC Iliac wings Bladder Color Doppler around bladder Iliac wings Bladder Male o Scrotum and penis Female o Labia 572 & 573 574 Landmarks Identified Pocket Protocol Reference Page

Sagittal Thorax/ Abdomen Sagittal

DIAPHRAGM RT

DIAPHRAGM LT

Stomach

Transverse

STOMACH

571

565

Transverse

KIDNEYS

Kidneys

566

Sagittal

RK SAG

567

Sagittal

LK SAG

569

Transverse Umbilical Cord

CI

570

568

Bladder/ Cord

Transverse

3VC

Bladder

Transverse

BLADDER GENDER

Gender

Transverse

(identify male or female)

2nd and 3rd Trimester OB Protocol

Fetal Spine and Extremities

Organ/ Order

Scan Plane

Label
CSP SAG

Landmarks Identified
Skull, cervical spine, and upper thorax o Sagittal view not available coronal is acceptable, label accordingly Distal neck, thorax, and upper abdomen o Sagittal view not available coronal is acceptable, label accordingly Lower abdomen to lower point of LSP o Sagittal view not available coronal is acceptable, label accordingly Spine up-just below skull, skin line Spine up-mid thorax, rib, skin line Spine up-iliac wings, skin line Shoulder, humerus and elbow Elbow, ulna, radius and wrist Wrist and fingers (open and closed) Shoulder, humerus and elbow Elbow, ulna, radius and wrist connections Wrist and fingers (open and closed) Femur and knee Knee, tibia, fibula and ankle o FRONTAL View Foot Toes Femur and knee Knee, tibia, fibula and ankle o FRONTAL View Foot Toes

Pocket Protocol Reference Page

555

Sagittal Sagittal TSP SAG

556

Spine

Sagittal

LSP SAG

557

Transverse Transverse Transverse Longitudinal Longitudinal Longitudinal Upper Extremity Longitudinal Longitudinal

CSP TX TSP TX LS-SP TX RT HUMERUS RT ULNA/RADIUS RT HAND LT HUMERUS LT ULNA/RADIUS LT HAND RT FEMUR RT TIB/FIB

559 560

584 w/o measurement 586 587 & 588 584 w/o measurement 586

Longitudinal Longitudinal Lower Extremity Longitudinal

587 & 588 583 w/o measurement 585

Coronal

RT FOOT

Longitudinal

LT FEMUR LT TIB/FIB

583 w/o measurement 585

Longitudinal Coronal LT FOOT

2nd and 3rd Trimester OB Protocol

Fetal Heart Fetal heart images will vary from site to site, all students are responsible for completing a sweep through the heart to determine situs and connection and recognize views Scan Plane Transverse fetal chest (IVS horizontal) Transverse fetal chest (IVS Vertical) Label AA Landmarks Identified Right and left atrium Foramen Ovale Right and left ventricle Tricuspid and Mitral Valves Spine Right and left atrium Foramen Ovale Right and left ventricle Tricuspid and Mitral Valves Spine Inferior vena cava Right atrium Superior vena cava Left ventricle Aortic valve Aortic root Proximal aorta 3 branches-innominate, left common carotid artery & left subclavian Thoracic aorta Right ventricle Pulmonary valve Pulmonary trunk RT ventricle Pulmonary valve RT pulmonary artery LT pulmonary artery Aorta Aortic valve Pulmonary trunk Ductus arteriosus Thoracic aorta AO SVC DA 563 564 Pocket Protocol Reference Page 562

Organ/Order

Subcostal 4 Chamber View

4CH SUBCOSTAL

Apical 4 Chamber View

4CH APICAL

Superior Vena Cava & Inferior Vena Cava Left Ventricular Outflow Tract

Long axis Sagittal fetal chest Long Axis Transverse fetal chest Sagittal Fetal Chest

SVC/IVC

LVOT

Aortic Arch

Right Ventricular Outflow Tract

Long Axis Transverse Fetal Chest

RVOT

Right Ventricular Outflow Tract

Short Axis Transverse Fetal Chest

RVOT SHORT

Ductus Arteriosus Arch

Sagittal Fetal Chest Transverse Fetal Chest

DA

3 Vessel View

3 VESSEL VIEW

2nd and 3rd Trimester OB Protocol

Normal Measurement Ranges Structure Amniotic Fluid Volume Sum of 4 amniotic fluid measurements Area of Interest Divide the uterus into 4 quadrants and measure the largest vertical pocket of amniotic fluid in each quadrant Plane Sagittal Measurement Greater than 20cm-abnormal Less than 5cmabnormal Comments Patient should be supine With the probe in the sagittal position, locate the largest pocket of amniotic fluid clear of all fetal parts Measure the fluid pocket from anterior to posterior (at least 1cm) Document this measurement for each quadrant of the uterus. Add the measurements for a total Measurement of the largest single vertical pocket of fluid in the uterus Commonly used for twin pregnancies

*measurement may vary per site Sagittal Greater than 10cm-Abnormal Less than 2cmAbnormal *measurement may vary per site Equal to gestational age Normal -less than 6mm up to 24 weeks gestation

Amniotic Fluid Largest Vertical Pocket

Single

Cerebellum

Posterior Fossa of the Brain Skin thickness on the posterior head

Sagittal

Move caudal from BPD, head must be symmetrical Same plane as cerebellum measurement

Nuchal Fold

Coronal

Cisterna Magna

Kidney Length

Anechoic Space in the Posterior Fossa Longest axis of the kidney

Coronal

Normal -less than 10 mm Approximately equal to gestational age through 2nd trimester

Same plane as cerebellum measurement

Sagittal

Long axis of the kidney measuring from superior to inferior pole

Lateral Ventricles

Amount of cerebrospinal fluid in ventricle

Coronal

Less than 10 mm

Superior to BPD at the level of the ventricles Measure at atrium or the thickest portion of the choroid plexus (CHP) or glomus

2nd and 3rd Trimester OB Protocol

Color and Spectral Doppler Analysis Structure Umbilical Artery Area of Interest Document umbilical artery blood flow with Color Doppler and Spectral Analysis in a free loop of the umbilical cord Plane Longitudinal Normal Measurement S/D= less than 3 after 30 week PI= less than 1.25 after 30 week RI-less than .7 after 30 weeks Longitudinal 2nd-3rd trimester= Continuous forward flow with increasing mean velocities until 37 weeks PI= Greater than 1.45 before term Less than 1 by term (Decreases after 32 weeks) Comments Angle correct is not needed Low resistive wave form High end diastolic flow is normal Absence of diastolic flow indicates fetus is in distress Reversal of diastolic flow is severe and seek immediate help from physician Pulsations can indicate a severe condition Fetal breathing movements will alter continuous forward flow pattern

Umbilical Vein

Middle Cerebral Artery

Document umbilical artery blood flow with Color Doppler and Spectral Analysis in a free loop of the umbilical cord Lateral branches of the circle of Willis

Coronal

Ductus Venosus

Shunt between the umbilical vein and inferior vena cava

Transverse Abdomen

Peak velocity= 50 cm/sec

Found slightly caudal to BPD plane Same proximal end Position the head to achieve a Doppler angle of zero or as close as possible High impedance flow with low diastolic flow Abnormal flow will display high diastolic flow Indicate pre-eclampsia, IUGR & anemia High diastolic component Evaluate the A waveabnormal if less than 5cm/sec