Level 3/ Anatomy/ Anatomy F^
• Document FHR using M-mode Doppler only. A minimum of 3-5 Doppler cycles should be obtained.
• Document bilateral adnexa.
• Document LUS and placental relationship.
o If a placental previa is suspected proceed to transvaginal ultrasound.
o If the placental edge is at or covers the internal os of the cervix, document a complete previa.
o A measurement less than 2cm between internal os of cervix and placental edge is considered a marginal previa.
• Document cervix and measure if possible.
o If suspected short cervix, funnel or patient reports recent bleeding and in patients at increased risk of PTD/PTL proceed to transvaginal ultrasound to evaluate cervical length.
o Have RN/APN collect fFN prior to transvaginal ultrasound when indicated.
• Identify placental location.
o Document placenta in long and transverse views.
o Patients with previous C-sections must have uterine wall evaluated using grayscale and color flow Doppler, to rule out accreta.
• Identify placental cord insertion using color flow doppler.
o A marginal cord insertion is anything less than 2 cm from edge of placenta.
o Velamentous cord insertion is seen when cord inserts beyond placental edge with vessels traveling to placenta.
• Establish and document fetal lie and situs.
• Obtain cranial biometry
o BPD x2 (minimum): at level of thalami, outer to inner border of fetal skull.
o HC x2 (minimum): same image/level as BPD, tracing outer skull without including skin line.
• Evaluate integrity and shape of cranial vault.
• Obtain and measure when needed intracranial anatomy.
o CSP
o Falx
o Thalami
o Bilateral choroid-dual screen
o Bilateral lateral ventricle (measure)-dual screen
o Posterior Fosa
Cerebellum (measure)
Cerebeller Vermis
4th Ventricle
Cisterna Magma (measure)
Nuchal Fold (measure 14w 0d-21w 6d)
• Image fetal facial anatomy.
• Fetal eye sockets
o Measures IOD (inner ocular diameter, inner-inner)
o Measures OOD (outer ocular diameter, outer-outer)
o Maxilla/Palate
o Mandible
o Fetal profile.
o Nasal Bone Measurement
o Nostrils and upper lip.
• Image fetal spine, shape and curvature and integrity of spine and overlying tissue, in long and transverse plane.
o Cervical spine
o Thoracic spine
o Lumbar spine
o Sacral spin
• Measure Humerus
o Measure at mid shaft at longest length.
• Measures Radius/Ulna
o Measure each at mid shaft at longest length.
• Image right arm.
o Upper
o Lower
• Image right hand
• Image left arm
o Upper
o Lower
• Image left hand
• Obtain a 4-chamber cine clip from fetal stomach to 4-chamber view of the heart noting the following anatomy:
o Right and left atria, should appear equal in size, with pulmonary veins seen entering the left atrium.
o Foramen ovale and flap should be seen moving in the left atrium.
o Right and left ventricles should appear equal in size. Right ventricle contains the moderator band and seen closest to chest wall.
o Ventricles are separated by intact septum.
o Tricuspid (R) and mitral (L) valves are seen moving freely during cardiac cycle with tricuspid valve seen slightly lower on IVS than mitral valve.
• Obtain thoracic circumference measurement, anteroposterior diameter and transthoracic diameter.
o Thoracic circumference should be measured in the axial plane at the level of the four-chamber view of the heart, parallel with the ribs, by placing an ellipse around the bony thorax
o The distance between spinal front edge and sternum rear edge is the thoracic anteroposterior diameter.
o A straight line drawn perpendicular to the anteroposterior diameter and between the two thoracic inner edges is the thoracic transverse diameter
• Obtain a still image of the 4-chamber heart
• Obtain a cardiac axis.
o The cardiac axis in a 4-chamber view is measured as the angle between the line tracing the long axis of the heart and the line bisecting the thorax in the anteroposterior direction.
• Obtain cine clip of the intraventricular septum using color flow Doppler at the level of the 4-chamber heart.
• Identify and image cardiac outflow tracts:
o LVOT originates from left ventricle, arching shortly after aortic valve.
o RVOT is seen originating from right ventricle and is seen to bifurcate shortly after pulmonary valve.
• Obtain 3VV and 3VTV with color flow Doppler.
• Obtain the 3VV by angling to fetal right shoulder including long pulmonary vein, aorta and transverse SVC
• Identify and image cardiac arches, aortic arch and ductal arch.
o Aortic arch arises from midline of fetal chest. This view should include the entire arch: ascending, arch with cranial branches and descending portions.
o Ductal arch is connection between main pulmonary artery and descending aorta. Ductal arch arises from anterior ventricle of the heart.
• Identify and image the superior vena cava (SVC) and the inferior vena cava (IVC)
• Obtain image of diaphragm in longitudinal view with heart seen above, and stomach seen below.
• Obtain abdominal biometry.
o AC x2 (minimum): measure abdomen in transverse plane at level of stomach and umbilical vein.
• Observe bowel for echogenicity or dilation.
• Document abdominal cord insertion.
• Identify and image bilateral fetal kidneys.
o Image each kidney in longitudinal view with adrenal gland seen superior to kidney.
o Image each kidney in transverse view. If fluid is noted in renal pelvis, measure in AP view, placing calipers on internal border of pelvis to evaluate for pyelectasis.
• Image renal arteries using color flow Doppler.
• Document abdominal cord insertion.
• Image fetal bladder.
o Use color flow Doppler at level of bladder to document the number of vessels in the umbilical cord.
• Measure femur
o FL x2 (minimum): measure femur at mid shaft at longest length.
• Measure tibia and fibula
o Measure each at mid shaft at longest length.
• Image right leg. (upper and lower if possible)
• Image right foot
• Image left leg (upper and lower if possible)
• Image left foot
• Amniotic Fluid Index (AFI):
o Divide the abdomen in 4 quadrants. Measure the largest vertical pocket of fluid (for each quadrant) not containing fetal parts or umbilical cord.
o Normal AFI is 5-24cm. Low AFI 5.1-7.9 cm. <5cm is oligohydramnios, >24cm is polyhydramnios and must be noted on report.
Contact appropriate Perinate or APN for low AFI or oligohydramnios.
• Document free floating 3 vessel cord.
• Obtain umbilical artery Dopplers. (after 23 weeks)
o Use pulsed wave Doppler to obtain waveform.
o Use High Q to measure velocities of a minimum of 3 waveforms.
o Repeat on a minimum of 2 cord segments. Obtain a third measurement if results in one segment are elevated.
o If RI is elevated (see graphs) in more than one segment, MCA’s must be performed.
• A Biophysical Profile is routinely performed on all fetuses 23 weeks and above.
• Ultrasound scoring is based on a 30-minute time frame with a maximum score of 8/8
AFI
Fetal gross body movements
Fetal tone
Fetal breathing movements
• Scoring a BPP:
o AFI
At least one amniotic fluid pocket must measure 2cm vertically, and must also measure at least 1cm across to meet criteria.
o Gross body movements:
3 or more discrete body or limb movements within 30 minutes
Fetal trunk movements or “body rolls”.
A minimum of 2 movements required to meet criteria.
o Fetal Tone
One or more episodes of active extension and flexion of a fetal extremity OR opening and closing of the hand within 30 minutes
Extension with immediate flexion. Opening and closing hand, mouth and kicking are examples.
A minimum of one complete extension/flexion movement required to meet criteria.
o Fetal Breathing Movements:
One or more episodes of fetal breathing lasting at least 30 seconds within 30 minutes.
Rhythmic contractions of the fetal diaphragm causing rise and fall of fetal chest.
Breathing movements must be sustained for 30 seconds to meet criteria.
• A note must be made in the body of the report points were not awarded for one or more of the above criteria.
o When NST included after 28-32 weeks, NST is scored and awarded points for reactivity with a maximum of 10/10. Reactivity is based on number and quality of FHR accelerations during 20-30 minute NST.
o A BPP score of less than 6/8 before 28 weeks must be reported to referring physician or perinate.
o A BPP score of less than 8/8 at 28 weeks and above requires that an NST be performed.
o A BPP score of less than 8/10 at 28 weeks and above, must be reported to referring physician.
• Obtain umbilical artery Dopplers.
o Use pulsed wave Doppler to obtain waveform.
o Use High Q to measure velocities of a minimum of 3 waveforms.
o Repeat on a minimum of 2 cord segments. Obtain a third measurement if results in one segment are elevated.
o If RI is elevated (see graphs) in more than one segment, central Dopplers must be performed.
• Complete ultrasound report, including any abnormal findings and scheduled follow up.