1

Obstetric and gynecologic ultrasound curriculum and competency

assessment in residency training programs: consensus report

A. ABUHAMAD, K. K. MINTON, C. B. BENSON, T. CHUDLEIGH, L. CRITES,

P. M. DOUBILET, R. DRIGGERS, W. LEE, K. V. MANN, J. J. PEREZ, N. C. ROSE,

L. L. SIMPSON, A. TABOR and B. R. BENACERRAF

Appendix S1

Details of competencies assessed during Levels 1–4 (Years 1–4), and additional
competencies, with corresponding images.

Criteria specified with an asterisk are essential to passing a competency. Missing any specified criterion fails the
competency for a particular image or movie clip.

1. Competency assessment: Level 1 (Year 1)

A. Mean sac diameter

B. Crown–rump length
C. Fetal presentation
D. Fetal extremities
E. Biparietal diameter
F. Head circumference
G. Abdominal circumference
H. Femur diaphysis length
I. Biophysical profile (ultrasound components)
J. Amniotic fluid index
K. Maximum vertical pocket
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Table 1A. Mean sac diameter

Pass grade:  7/9.

Two images are required for this competency.

Image 1:
• Image magnified appropriately.
• Focal zone at appropriate level.
• Ultrasound plane at widest dimensions of gestational sac.
• Gestational sac measured in two orthogonal dimensions using inner-to-inner technique.

Image 2:
• Image magnified.
• Focal zone at appropriate level.
• Ultrasound plane of gestational sac perpendicular to that of Image 1.
• Gestational sac measured at widest dimension using inner-to-inner technique.
• *Mean sac diameter appropriately calculated from mean of all three dimensions from Images 1 and 2.

Figure 1a Gestational sac visualized in sagittal plane of uterus. Note length and height of gestational sac
(measurements 1 and 2, respectively).

Figure 1b Maximum width of gestational sac measured in plane perpendicular to that of Figure 1a. Mean sac
diameter is calculated from mean of length, height (Figure 1a) and width (Figure 1b).
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Table 1B. Crown–rump length

Pass grade:  4/5.

• Focal zone at appropriate level.

• Image magnified appropriately.
• Embryo/fetus imaged in neutral position.
• Maximum length of embryo/fetus shown.
• Maximum length of embryo/fetus measured in straight line from cranial to caudal.

Figure 2 Mid-sagittal plane in a fetus at 12 weeks and 5 days, showing crown–rump length (CRL)
measurement.
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Table 1C. Fetal presentation

Pass grade: 2/3.

• Focal zone at appropriate level.

• Longitudinal view of lower uterine segment above level of maternal pubic bone.
• *Fetal presenting body part identified in relation to cervix.

Figure 3a Mid-sagittal plane of uterus in lower uterine segment, showing cephalic presentation (fetal head).
Note mid-sagittal view of the cervix.

Figure 3b Mid-sagittal plane of uterus in lower uterine segment, showing breech presentation (fetal buttocks).
Note mid-sagittal view of the cervix.
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Table 1D. Fetal extremities

Pass grade: 5/7.

Four† images are required for this competency.

• Focal zone at appropriate level.

• Image magnified appropriately.
• Longitudinal view of extremity shown.

Image 1:
• Right upper extremity, showing hand if possible.

Image 2:
• Left upper extremity, showing hand if possible.

Image 3:
• Right lower extremity, showing foot if possible.

Image 4:
• Left lower extremity, showing foot if possible.

†Fewer than four images are acceptable if both extremities are displayed clearly in a single image.

Figure 4a Ultrasound image of upper fetal extremity. Note appearance of humerus, ulna and radius. Small
portion of radius is shown, due to orientation of upper extremity.

Figure 4b Ultrasound image of lower fetal extremities.

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Table 1E. Biparietal diameter: transthalamic plane

Pass grade: 10/13.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Axial plane of head.
• Symmetric appearance of cerebral hemispheres.
• Midline falx imaged.
• Thalami imaged.
• Cavum septi pellucidi imaged.
• Insula imaged.
• No cerebellum seen.
• Near caliper on outside edge of bone.
• Far caliper on inside edge of bone†.
• Measurement at widest diameter.
• Measurement perpendicular to falx.

†Caliper may be placed on outer edge of bone based on existing practice patterns.
Passing this competency will also qualify for competency ‘transthalamic plane’ in Table 3B.

Figure 5a Axial plane of fetal head at level of biparietal diameter (BPD), demonstrating falx cerebri, cavum
septi pellucidi (CSP), thalami (T), third ventricle (3 rd V) and insula. Note, BPD measurement in this image is
from outside border of proximal parietal bone to inside border of distal parietal bone.

Figure 5b Same image as in Figure 5a. BPD measurement in this image is from outside border of proximal
parietal bone to outside border of distal parietal bone.
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Table 1F. Head circumference

Pass grade: 7/10.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Axial plane of head.
• Symmetric appearance of cerebral hemispheres.
• Midline falx imaged.
• Thalami imaged.
• Cavum septi pellucidi imaged.
• Insula imaged.
• No cerebellum seen.
• Measurement circumference ellipse on outside edge of bone.

Passing this competency will also qualify for competency ‘transthalamic plane’ in Table 3B.

Figure 6 Axial plane of fetal head at biparietal diameter level (transthalamic), demonstrating falx cerebri,
cavum septi pellucidi (CSP), thalami (T), third ventricle (3rd V) and insula. Measurement of head circumference
(HC) is obtained using an ellipse placed on outer edge of cranium. In this case, HC measures 21.74 cm,
corresponding to gestational age of 23 weeks and 6 days.
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Table 1G. Abdominal circumference

Pass grade: 8/11.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Axial plane of abdomen.
• Abdomen as circular as possible.
• Spine imaged in cross-section in 3- or 9-o’clock position if possible.
• Stomach bubble imaged.
• Intrahepatic portion of umbilical vein imaged in a short segment.
• No more than one rib visible on each side laterally.
• Kidneys not visualized.
• Surrounding skin seen in entirety if possible.
• Measurement of circumference ellipse on outside edge of skin.

Passing this competency will also qualify for competency ‘abdominal circumference level’ in Table 3H.

Figure 7 Axial plane of fetal abdomen at level of abdominal circumference. Note presence of intra-abdominal
portion of umbilical vein (UV), stomach (St), spine (Sp), descending abdominal aorta (Ao) and inferior vena
cava (IVC). Also note presence of large segments of individual ribs on each side laterally.
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Table 1H. Femur diaphysis length

Pass grade: 5/7.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Whole femur diaphysis imaged.
• Ultrasound beam perpendicular to long axis of femur.
• Calipers placed at each end of ossified diaphysis.
• Longest visible diaphysis is measured.
• Spur artifacts on end of diaphysis not included in measurement.

Figure 8 Longitudinal plane of femur, showing femur diaphysis length (FL) measurement. Note proximal and
distal femoral epiphyses are not yet ossified and not included in FL measurement. Also note presence of distal
femoral spur, which should not be included in FL measurement.

Table 1I. Biophysical profile (ultrasound components)

Pass grade: 6/6.

• *Length of examination: 30 min maximum, or until all criteria are met.

• *Breathing, movement and tone documented by movie clips if available.
• *30-second period of fetal breathing imaged
• *Three gross fetal body or limb movements imaged.
• *Episode of flexion and extension of fetal limb(s) imaged.
• *Amniotic fluid volume evaluated by amniotic fluid index (AFI), maximum vertical pocket or qualitative
assessment.
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Table 1J. Amniotic fluid index

Pass grade: 6/8.

• Focal zone at appropriate level.

• Image at appropriate depth.
• Sagittal orientation of ultrasound transducer.
• Four images labeled, one for each quadrant.
• Calipers placed on each image from top to bottom of maximum vertical pocket.
• Fluid space measured is devoid of any cord or body part.
• Measurement is vertical with respect to transducer placement.
• Four quadrant measurements are added for amniotic fluid index calculation.

Figure 9 Four images (Q1–Q4), one obtained from each of four quadrants of uterus. Maximum vertical pocket
(MVP) is measured in each quadrant (Q1–Q4). Amniotic fluid index (AFI) is calculated by adding MVP from
all four quadrants. In this fetus, AFI is normal (13.7 cm). MVP is measured in amniotic fluid from top to
bottom in a vertical line.
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Table 1K. Maximum vertical pocket

Pass grade 4/6.

• Focal zone at appropriate level.

• Image at appropriate depth.
• Image displays maximum vertical pocket of amniotic fluid.
• Calipers placed from top to bottom of maximum vertical pocket.
• Fluid space measured is devoid of any cord or body parts.
• Measurement is vertical with respect to transducer placement.

Figure 10 Ultrasound image of maximum vertical pocket (MVP) for determination of amniotic fluid volume.
MVP is determined by scanning all four quadrants of uterus and measuring MVP in quadrant with largest
amount of amniotic fluid. MVP is measured in amniotic fluid from top to bottom in a vertical line.
 12

2. Competency assessment: Level 2 (Year 2)

A. Cervical length (transvaginal ultrasound)
B. Cervical length (transabdominal ultrasound)
C. Endometrial thickness
D. Uterine measurements
E. Ovarian measurements
F. Transvaginal pelvic examination: uterus
G. Transvaginal pelvic examination: ovaries

Table 2A. Cervical length (transvaginal ultrasound)

Pass grade: 7/10.

• Transvaginal ultrasound.
• Mid-sagittal plane of cervix.
• Focal zone at appropriate level.
• Image magnified appropriately.
• Anterior cervical width is equal to posterior cervical width.
• Maternal bladder empty.
• Internal os seen.
• External os seen.
• Cervical canal visible throughout.
• Caliper placement correct.

Figure 11 Mid-sagittal plane of cervix obtained by transvaginal approach. Cervical length is measured from
internal cervical os to external cervical os (3.8 cm in this example). Note anterior position of maternal bladder
and presenting fetal head.
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Table 2B. Cervical length (transabdominal ultrasound)

Pass grade: 6/8.

• Transabdominal ultrasound.
• Focal zone at appropriate level.
• Image magnified appropriately.
• Mid-sagittal plane of cervix.
• Maternal bladder non-distended.
• Internal os seen.
• External os seen.
• Caliper placement correct.

Figure 12 Mid-sagittal plane of cervix obtained by transabdominal approach. Cervical length is measured from
internal os to external cervical os (4 cm in this example). Fetal head is presenting. Note location of vaginal
canal. Distention of maternal bladder may impact measurement of cervical measurement on transabdominal
approach.
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Table 2C. Endometrial thickness

Pass grade: 5/7.

• *Transvaginal ultrasound.
• Focal zone at appropriate level.
• Mid-sagittal plane of cervix and uterus, with magnification of endometrium as needed for endometrial
measurement.
• Endometrial lining (echo) seen in its entirety from cervical canal to endometrial fundus.
• Cul-de-sac imaged posterior to cervix.
• Calipers placed in anteroposterior orientation, perpendicular to long axis of uterus, using outer-to-outer
technique†.
• Widest endometrial thickness measured using outer-to-outer technique.

†In presence of endometrial fluid, measure anterior and posterior endometrial walls separately and add the two
measurements.

Figure 13 Mid-sagittal plane of uterus obtained for measurements of endometrial thickness. Note midline
endometrial lining (echo) is seen in its entirety from cervical canal to endometrial fundus. Measurement of
endometrial thickness is obtained by placing calipers in an anteroposterior orientation, perpendicular to long
axis of uterus and using outer-to-outer technique.
 15

Table 2D. Uterine measurements

Pass grade: 7/10.

Two images (14A1 or 14A2, and 14B) are required for this competency.

• Transvaginal ultrasound.
• Focal zone at appropriate level.
• Image magnified appropriately.

Image 1:
• Mid-sagittal plane of cervix and uterus.
• Endometrial lining seen in its entirety from cervical canal to endometrial fundus.
• Cul-de-sac imaged posterior to cervix.
• Length of uterus measured from fundus to external os using outer-to-outer technique†. An alternate method
for measurement of uterine length includes measurement from fundal region, along endometrial lining and
endocervical canal, using outer-to-outer technique.
• Anteroposterior diameter of uterus measured from anterior to posterior serosal surface at widest dimension
perpendicular to long axis of uterus using outer-to-outer technique.

Image 2:
• Transverse (axial) plane of uterus at widest dimension.
• Transverse diameter of uterus measured from left to right serosal surface at widest dimension using outer-
to-outer technique.

†Morphological Uterus Sonographic Assessment (MUSA) is another method that can be followed/used for
uterine measurement13.

Passing this competency will also qualify for competency ‘Transvaginal pelvic examination: uterus’ in Table
2F.

Figure 14a1 Mid-sagittal plane of uterus obtained for measurements of uterine length and height. Note
endometrial lining (echo) is seen in its entirety from cervical canal to endometrial fundus. Length of uterus
(measurement 1 in this image) is measured from fundus to outer edge of cervix. In this mid-sagittal plane,
anteroposterior diameter of uterus is also measured at widest dimension (measurement 2 in this image),
perpendicular to long axis of uterus.
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Figure 14a2 Mid-sagittal plane of uterus obtained for measurement of uterine length and height. Note
endometrial lining (echo) is seen in its entirety from cervical canal to endometrial fundus. Length of uterus
(measurement 1 in this figure) is measured from fundus to outer edge of cervix, following endometrial lining
and endocervical canal, using outer-to-outer technique. This technique of uterine measurement allows for more
accuracy in presence of uterine flexion. In this mid-sagittal plane, anteroposterior diameter of uterus is also
measured at widest dimension (measurement 2 in this figure), perpendicular to long axis of uterus.

Figure 14b Transverse plane of uterus, shown at its widest dimension. Uterine width is measured from left to
right at widest uterine dimension.
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Table 2E. Ovarian measurements

Pass grade: 6/8.

Two images are required for this competency.

Perform for left and for right ovary.

• Transvaginal ultrasound.
• Focal zone at appropriate level.
• Image magnified appropriately.

Image 1:
• Plane of pelvis showing ovary with clear outline in longest dimension.
• Length of ovary measured from anterior to posterior at longest dimension.
• Anteroposterior diameter of ovary measured from left to right, orthogonal to length measurement.

Image 2:
• Plane of pelvis showing ovary with clear outline at right angles to Image 1.
• Width of ovary measured from left to right at widest dimension.

Passing this competency will also qualify for competency ‘Transvaginal pelvic examination: ovaries’ in Table
2G.

Figure 15a Longitudinal plane of ovary, showing measurements of ovarian length and anteroposterior
diameter. Anteroposterior diameter is measured perpendicular to length measurement.
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Figure 15b Axial plane of ovary, perpendicular to longitudinal plane (Figure 15a), showing ovarian width
measurement.
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Table 2F. Transvaginal pelvic examination: uterus

Pass grade: 5/7.

Two images are required for this competency.

• Transvaginal ultrasound.
• Focal zone at appropriate level.
• Image magnified appropriately.

Image 1: Longitudinal view.

• Mid-sagittal plane of cervix and uterus.
• Endometrial lining seen in its entirety from cervical canal to endometrial fundus.
• Cul-de-sac imaged posterior to cervix.

Image 2: Axial view.

• Axial plane of uterus at widest dimension.

Competency for this plane can also be established as part of uterine measurement competency in Table 2D.
See Figure 14.

Table 2G. Transvaginal pelvic examination: ovaries

Pass grade: 3/4.

Two images are required for this competency.

Perform for left and for right ovary.

• Focal zone at appropriate level.
• Image magnified appropriately.

Image 1:
• Parasagittal plane of pelvis showing ovary with clear outline in longest dimension.

Image 2:
• Axial plane of pelvis showing ovary with clear outline at right angles to Image 1.

Competency for this plane can also be established as part of ovarian measurement competency in Table 2E.
See Figure 15.
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3. Competency assessment: Level 3 (Year 3)

A. Head: transventricular plane
B. Head: transthalamic plane
C. Head: transcerebellar plane
D. Face: upper lip and philtrum
E. Four-chamber view
F. Left ventricular outflow tract (LVOT)
G. Right ventricular outflow tract (RVOT)
H. Abdomen: abdominal circumference level
I. Abdomen: kidneys
J. Abdomen: cord insertion
K. Number of cord vessels
L. Pelvis: bladder
M. Spine: longitudinal
N. Spine: axial
O. Writing an ultrasound report: Obstetrics
P. Writing an ultrasound report: Gynecology

Table 3A. Head: transventricular plane

Pass grade: 6/8.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Axial plane of head.
• Symmetric appearance of cerebral hemispheres.
• Midline falx imaged.
• Atrium and occipital horn of lateral ventricle clearly imaged.
• Measurement of atrium of lateral ventricle at level of parieto-occipital groove.
• Calipers placed on medial and lateral walls of atrium of lateral ventricle perpendicular to long axis of
ventricle using inner-to-inner technique.

Figure 16 Axial view of fetal head at level of transventricular plane. Note atrium and occipital horns of lateral
ventricle and choroid plexus within. Measurement of lateral ventricle is obtained at the atrium, at level of
parieto-occipital groove. Calipers are placed on medial and lateral walls, perpendicular to long axis of
ventricle, using inner-to-inner technique. Although cavum septi pellucidi (CSP) is seen in this figure, it does
not have to be visualized as, on many occasions, the lateral ventricle can be seen in a plane that is superior to
the CSP.
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Table 3B. Head: transthalamic plane

Pass grade: 7/9.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Axial plane of head.
• Symmetric appearance of cerebral hemispheres.
• Midline falx imaged.
• Thalami imaged.
• Cavum septi pellucidi imaged.
• Insula imaged.
• No cerebellum seen.

Competency for this plane can also be established as part of biparietal diameter/head circumference
measurement competencies, as shown in Tables 1E and 1F.
See Figure 5.

Table 3C. Head: transcerebellar plane

Pass grade: 7/9.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Angled axial plane of head.
• Symmetric appearance of cerebellar hemispheres.
• Midline falx imaged.
• Thalami imaged.
• Cavum septi pellucidi imaged.
• *Cerebellar vermis imaged.
• *Cisterna magna imaged.

Figure 17 Transcerebellar plane. Angled axial plane of fetal head, showing posterior fossa. Note symmetric
appearance of cerebellar hemispheres, cerebellar vermis and cisterna magna. In this plane, falx cerebri, cavum
septi pellucidi (CSP) and thalami (T) are also seen.
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Table 3D. Face: upper lip and philtrum

Pass grade: 3/4.

• Focal zone at appropriate level.

• Image magnified appropriately.
• Coronal view of upper lip and philtrum.
• *Soft tissue of upper lip, philtrum and nares clearly imaged.

Figure 18 Coronal view of fetal face, showing upper lip and philtrum. Note appearance of soft tissue of upper
lip, philtrum and nares.
 23
Table 3E. Four-chamber view

Pass grade: 5/7.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Transverse (axial) plane of the fetal chest.
• No more than one rib seen on each side of the chest laterally.
• Chest as circular as possible.
• Spine imaged in cross section.
• *Four chambers imaged.

Figure 19 Axial view of fetal chest at level of four-chamber view of heart. Note appearance of the four
chambers with right ventricle (RV) as most anterior chamber, and left atrium (LA) as most posterior chamber.
Left ventricle (LV) and right atrium (RA) are also seen. Note location of descending thoracic aorta (Ao), and
spine (Sp) posteriorly. Note that apex of heart is towards fetal left side and also note presence of large
segments of individual ribs.
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Table 3F. Left ventricular outflow tract

Pass grade: 4/5.

• Focal zone at appropriate level.

• Image magnified appropriately.
• Angled axial plane of fetal chest.
• *LVOT imaged with continuity of ascending aorta with ventricular septum.
• LVOT imaged with no division of ascending aorta (which excludes transposition).

Figure 20 Angled axial plane of fetal chest, showing left ventricular outflow tract and aorta (Ao). Note Ao
arising from left ventricle (LV), and continuity of Ao with ventricular septum. LA, left atrium; RA, right
atrium; RV, right ventricle.
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Table 3G. Right ventricular outflow tract

Pass grade: 3/4.

• Focal zone at appropriate level.

• Image magnified appropriately.
• Transverse or parasagittal plane of upper fetal chest.
• *RVOT imaged with pulmonary valve shown.

Figure 21 Transverse plane of fetal upper chest at level of right ventricular outflow tract. Note pulmonary
artery (PA), superior to the aorta (Ao). Also note pulmonary valve (PV).

Table 3H. Abdomen: abdominal circumference level

Pass grade: 7/10.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Axial plane of abdomen.
• Abdomen as circular as possible.
• Spine imaged in cross-section in 3- or 9-o’clock position if possible.
• Stomach bubble imaged.
• Intrahepatic portion of umbilical vein imaged in a short segment.
• No more than one rib visible on each side laterally.
• Kidneys not visualized.
• Surrounding skin seen in its entirety if possible.

Competency for this plane can also be established as part of abdominal circumference measurement
competency, as shown in Table 1G.
See Figure 7.
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Table 3I. Abdomen: kidneys

Pass grade: 3/4.

• Focal zone at appropriate level.

• Image magnified appropriately.
• Coronal, parasagittal or axial view of abdomen.
• *Right and left kidneys imaged in one or two images.

Figure 22a Axial plane of fetal abdomen at level of kidneys. Note right and left kidneys and renal pelves,
imaged in posterior aspect of fetal abdomen, lateral to fetal spine.

Figure 22b Coronal plane of fetal posterior abdomen. Note presence of right and left kidneys in coronal view.
 27

Figure 22c Sagittal plane of right side of abdomen, showing right kidney.

Table 3J. Abdomen: cord insertion

Pass grade: 3/4.

• Focal zone at appropriate level.

• Image magnified appropriately.
• Axial or mid-sagittal plane of abdomen.
• *Umbilical cord imaged inserting into anterior abdominal wall, outlined by amniotic fluid, with
abdominal wall visualized clearly on both sides of cord insertion.

Figure 23 Axial plane of fetal abdomen at level of cord insertion. Note insertion of umbilical cord into anterior
abdominal wall.
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Table 3K. Number of cord vessels

Pass grade: 3/4.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Cross-sectional view of umbilical cord in amniotic fluid or axial view of fetal pelvis with color
Doppler.
• *Presence of two fetal umbilical arteries around the bladder.

Figure 24a Axial plane of fetal pelvis (color Doppler) at level of fetal bladder. Note presence of two umbilical
arteries, lateral to bladder.

Figure 24b Axial plane (grayscale) of free loop of umbilical cord in amniotic fluid, showing umbilical vein and
two umbilical arteries.
 29

Figure 24c Axial plane (color Doppler) of free loop of umbilical cord in amniotic fluid (as in Figure 24b),
showing umbilical vein and two umbilical arteries. Note that blood flow in umbilical vein is in reverse direction
to that of umbilical artery.

Table 3L. Pelvis: bladder

Pass grade: 3/4.

• Focal zone at appropriate level.

• Image magnified appropriately.
• Coronal, sagittal or axial view of abdomen/pelvis.
• *Bladder imaged in anterior aspect of pelvis.

Figure 25 Axial plane of fetal lower abdomen and pelvis, showing fetal bladder in its anterior position. In this
axial plane, cross-sections of femora are noted in lower extremity.
 30

Table 3M. Spine: longitudinal

Pass grade: 5/7.

Three images/sweeps are required for this competency.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Mid-sagittal plane of spine.
• *Overlying skin imaged outlined by amniotic fluid.

Image 1:
• *Entire length of cervical spine evaluated.

Image 2:
• *Entire length of thoracic spine evaluated.

Image 3:
• *Entire length of lumbosacral spine evaluated.

Figure 26a Mid-sagittal plane of fetal spine at level of cervical and thoracic region. Note that entire length of
cervical and thoracic spine is shown, with normal overlying skin and no spinal abnormalities. Spinous process
and corresponding vertebral body is seen for each vertebra.
 31

Figure 26b Mid-sagittal plane of fetal spine at level of thoracic region. Note that entire length of thoracic spine
is shown, with normal overlying skin and no spinal abnormalities. Spinous process and corresponding vertebral
body is seen for each vertebra.

Figure 26c Mid-sagittal plane of fetal spine at level of lumbosacral region. Note that entire length of
lumbosacral spine is shown, with normal overlying skin and no spinal abnormalities. Spinous process and
corresponding vertebral body is seen for each vertebra.
 32
Table 3N. Spine: axial

Pass grade: 5/7.

Three images/sweeps are required for this competency.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Axial plane(s) of spine.
• Overlying skin imaged outlined by amniotic fluid.

Image/Sweep 1:
• *Entire length of cervical spine evaluated.

Image/Sweep 2:
• *Entire length of thoracic spine evaluated.

Image/Sweep 3:
• *Entire length of lumbosacral spine evaluated.

Figure 27a Axial plane of fetal spine at level of cervical spine. Note normal orientation of spinal lateral
processes and normal overlying skin.
 33

Figure 27b Axial plane of fetal spine at level of thoracic spine. Note normal orientation of spinal lateral
processes and normal overlying skin.

Figure 27c Axial plane of fetal spine at level of lumbosacral spine. Note normal orientation of spinal lateral
processes and normal overlying skin. Iliac bones are seen in the pelvis laterally on each side.
 34

Table 3O. Writing an ultrasound report: Obstetrics

Pass grade is assessed subjectively based on review of listed criteria.

Ensure that essential criteria (*) are included as appropriate.

Patient identification and pertinent characteristics:

• *Patient name.
• *Identification numbers.
• *Examination date.
• Patient date of birth.
• Patient gravidity and parity if clinically relevant.
• Pregnancy dating as available.
• *Indication for ultrasound examination.

Basic information:
• * Presence or absence of cardiac activity.
• *Location of gestational sac.
• *Number of fetuses.
• *Location of fetuses in multiple pregnancy.
• *Placental location.
• *Type of placentation in multiple pregnancy.
• *Assessment of amniotic fluid.
• *Fetal lie and presentation.

Fetal biometric measurements:

• *Mean sac diameter (if no embryo/fetus).
• *Crown–rump length.
• *Biparietal diameter.
• *Head circumference.
• *Abdominal circumference.
• *Femur diaphysis length.

Fetal anatomy:
• Described appropriate to setting and resources.
• *Basic anatomy.
• Detailed anatomy.
• *Estimated gestational age based on established guidelines.
• *Estimated fetal weight (after 24 weeks).
• *Summary of examination and comments.
• Comparison with previous studies.
• Limitations of ultrasound examination.
• Recommendations for follow-up if necessary.
 35

Table 3P. Writing an ultrasound report: Gynecology

Pass grade is assessed subjectively based on review of listed criteria.

Ensure that essential criteria (*) are included as appropriate.

Patient identification and pertinent characteristics:

• *Patient name.
• *Identification numbers.
• *Date of examination.
• Patient date of birth.
• Patient gravidity and parity if clinically relevant.
• Mode of previous delivery(ies) if applicable.
• Date of last menstrual period.
• *Indication for ultrasound examination.

Biometric information:
• *Uterine height, length and width.
• *Ovarian measurements in three dimensions are a required part of imaging, but not of written report.
• *Cul-de-sac: fluid or abnormalities.

Abnormalities:
• *Uterine.
• *Adnexal.
• *Cul-de-sac.
• *Surrounding pelvic structures.

Final diagnosis and follow-up:

• *Summary of examination and comments.
• Comparison with previous studies.
• Limitations of ultrasound examination.
• Recommendations for follow-up if necessary.
 36

4. Competency assessment: Level 4 (Year 4)

A. Face: facial profile
B. Amniocentesis to assess fetal lung maturity

Table 4A. Face: facial profile

Pass grade: 5/7.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Mid-sagittal view of face.
• Tip of nose imaged.
• Nasal bone imaged.
• Mandible imaged.
• Maxilla imaged.

Figure 28 Mid-sagittal plane of fetal face, showing facial profile. Note tip of nose, nasal bone, maxilla and
mandible.

Table 4B. Amniocentesis to assess fetal lung maturity

For obstetric and gynecologic residents only.

Pass grade is assessed subjectively based on review of listed criteria.

Indication for amniocentesis

• Written and oral information provided.
• Informed consent signed.
• Maternal blood type reviewed.

Procedure
• Timeout before procedure.
• Fetal viability established before procedure.
• Needle insertion performed under ultrasound guidance.
• Transplacental puncture avoided if possible.
• Needle gauge 22–20.
• Maximum of two insertions.
• Volume of amniotic fluid retrieved as needed for test.
• Fetal wellbeing: assessment of fetal heart rate after procedure.
• Rhogam administered if indicated.
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5. Additional competencies
Additional competencies listed here are not currently part of the basic obstetric and gynecologic ultrasound
examination. Programs may opt to add these competencies as part of ultrasound training.

A. Three vessels and trachea view

B. Face: orbits
C. Umbilical artery Doppler
D. Nuchal translucency
E. Saline contrast sonohysterography

Table 5A. Three vessels and trachea view

Pass grade: 6/8.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Angled axial plane of fetal upper chest.
• Spine imaged in cross-section.
• Pulmonary artery/ductal arch imaged as anterior vessel.
• Ascending aorta/aortic isthmus imaged as middle vessel.
• Superior vena cava imaged in cross-section as posterior vessel.
• Ductal arch and aortic arch meet and both are shown to left of trachea.

Figure 29a Angled axial plane of fetal upper chest, showing three vessels and trachea view. Note anterior
location of pulmonary artery (PA), with ductus arteriosus (DA) connecting with descending aorta (Descending
Ao). Aorta (Ao) and aortic isthmus (Ao Isthmus) are also seen connecting with descending Ao. Superior vena
cava (SVC) is seen in cross-section to right side of aorta. Note that DA and Ao isthmus are to left side of
trachea, confirming presence of normal left aortic and ductal arches. Spine (Sp) is seen posteriorly.
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Figure 29b Angled axial plane of fetal upper chest, showing three vessels and trachea view with color Doppler.
Note that color Doppler shows blood flow in both ductal arch (DA) and aortic isthmus (Ao Isthmus) towards
descending aorta (Descending Ao). Ao, aorta; PA, pulmonary artery; Sp, spine; SVC, superior vena cava.

Table 5B. Face: orbits

Pass grade: 3/4.

• Focal zone at appropriate level.

• Image magnified appropriately.
• *Coronal or axial views of upper face, showing two orbits in same image.
• Bony edges of both orbits clearly imaged.

Figure 30 Axial view of upper face, showing two bony orbits.

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Table 5C. Umbilical artery Doppler

Pass grade: 7/9.

• A loop of umbilical cord imaged.

• Image magnified appropriately.
• Color Doppler applied if necessary.
• *Sample Doppler gate on umbilical artery.
• Wall filter sufficiently low to detect low-velocity flow.
• Scale and baseline set so waveforms occupy > 50% of height of Doppler scale.
• Doppler velocimetry tracing demonstrates at least five consecutive similar waveforms.
• Doppler velocimetry tracing acquired in absence of fetal breathing and hiccups.
• Waveform(s) selected for measurements (pulsatility index, resistance index or S/D ratio) are similar.

Figure 31 Color and pulsed Doppler of umbilical artery obtained at level of placental cord insertion. Note that
Doppler waveforms show forward flow during diastole (D). Note also peak of waveforms, corresponding to
peak systole (S).
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Table 5D. Nuchal translucency

Pass grade: 7/9

• Mid-sagittal plane of fetus.

• Image magnified with fetal head occupying majority of ultrasound image.
• Fetal head in neutral position.
• Fetus observed away from amnion.
• Margins of nuchal translucency (NT) edges clear.
• Calipers (+) used.
• Caliper horizontal cross bars are placed on NT line.
• Calipers placed perpendicular to long axis of fetus.
• Measurement is at widest NT space using ‘on-to-on’ technique.

Nuchal translucency measurement requires official certification before clinical practice.

Figure 32 Mid-sagittal plane of fetus in first trimester of pregnancy, showing measurement of nuchal
translucency (NT). Note in this mid-sagittal plane, tip of nose, maxilla and mid brain are all visible. Also note
that amnion is seen as a separate membrane. Measurement of NT is performed by placement of calipers at
widest NT space, using ‘on-to-on’ technique.
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Table 5E. Saline contrast sonohysterography

Pass grade: review components with trainee.

Preparation for procedure:

• Review indication for procedure.
• Ensure no contraindications for procedure exist.
• Obtain informed consent.
• Evaluate for presence of sexually transmitted diseases and need for antibiotic prophylaxis.
• Prepare required equipment.
• Ensure timing of procedure is in early proliferative phase and when patient is not actively bleeding.

Procedure:
• Timeout performed before procedure.
• Patient in supine position.
• Transvaginal ultrasound used.

Image criteria:
• Long-axis view of endometrial cavity during fluid injection.
• Adequate endometrial cavity distension (probe pressure at internal os in sagittal orientation to maintain
distension).
• Three-dimensional volume if available: sagittal, transverse and coronal views.
• Two-dimensional views:
• Sagittal view: to include entire endometrial cavity.
• Transverse view: fundus, mid-uterine and lower-uterine segments.
• Real-time evaluation of endometrial cavity with targeted image capture.
• Endometrial wall thickness: anterior and posterior walls measured separately.
• Define/describe endometrium: global/uniform, focal irregularity (mass, polyp or fibroid).

Figure 33a Mid-sagittal plane of uterus obtained during saline contrast sonohysterography. Note distended
endometrial cavity and sonohysterography catheter in isthmic portion of uterus. Note that cavity is normal
without any visible abnormality.
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Figure 33b Three-dimensional (3D) ultrasound volume of uterus obtained during sonohysterography. Note
transverse plane in A, sagittal plane in B, and coronal plane in C. 3D coronal plane is also displayed in lower
right quadrant. Note that coronal planes in two-dimensional and 3D images show normal endometrial cavity
without any abnormality.