Original Research

Standardized Six-Step Approach to the

Performance of the Focused Basic
Obstetric Ultrasound Examination
Alfred Abuhamad, MD1 Yili Zhao, MD1 Sharon Abuhamad, RDMS1 Elena Sinkovskaya, MD, PhD1
Rashmi Rao, MD2 Camille Kanaan, MD1 Lawrence Platt, MD2,3

1 Department of Obstetrics and Gynecology, Eastern Virginia Medical Address for correspondence Alfred Abuhamad, MD, Department of
School, Norfolk, Virginia Obstetrics and Gynecology, Eastern Virginia Medical School, 825
2 Department of Obstetrics and Gynecology, David Geffen School of Fairfax Avenue, Norfolk, VA 23507 (e-mail: abuhamaz@evms.edu).
Medicine at UCLA, Los Angeles, California
3 Center for Fetal Medicine and Women’s Ultrasound, Los Angeles,
California

Am J Perinatol

Abstract Objectives This study aims to validate the feasibility and accuracy of a new standard-

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ized six-step approach to the performance of the focused basic obstetric ultrasound
examination, and compare the new approach to the regular approach performed in the
scheduled obstetric ultrasound examination.
Study Design A new standardized six-step approach to the performance of the
focused basic obstetric ultrasound examination, to evaluate fetal presentation, fetal
cardiac activity, presence of multiple pregnancy, placental localization, amniotic fluid
volume evaluation, and biometric measurements, was prospectively performed on 100
pregnant women between 18þ0 and 27þ6 weeks of gestation and another 100 pregnant
women between 28þ0 and 36þ6 weeks of gestation. The agreement of findings for each
of the six steps of the standardized six-step approach was evaluated against the regular
approach.
Keywords Results In all ultrasound examinations performed, substantial to perfect agreement
► six-step approach (Kappa value between 0.64 and 1.00) was observed between the new standardized six-
► focused basic step approach and the regular approach.
obstetric ultrasound Conclusion The new standardized six-step approach to the focused basic obstetric
► limited resource ultrasound examination can be performed successfully and accurately between 18þ0
settings and 36þ6 weeks of gestation. This standardized approach can be of significant benefit to
► fetus limited resource settings and in point of care obstetric ultrasound applications.

Obstetric ultrasonography is considered an integral part of
prenatal care as it has been shown to accurately date a pregnan-
cy, identify pregnancy risk factors, and diagnose fetal abnor-
malities. In limited resource settings, the availability of
ultrasound is restricted by the relatively high cost of equipment
and lack of trained health care workers. As ultrasound equip-
ment has become cheaper and increasingly portable, its avail-
ability in the limited resource settings is expanding. A major
limitation of the ultrasound imaging modality is related to its
operator dependency with a fairly steep curve to competency. In
the field of obstetrics, fetal movement, and variable fetal posi-
tion in the uterus further affect ultrasound imaging.
Based upon our experience with ultrasound in limited
resource settings, we have identified six components of the

received Copyright © by Thieme Medical DOI http://dx.doi.org/

June 23, 2015 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0035-1558828.
accepted after revision New York, NY 10001, USA. ISSN 0735-1631.
June 28, 2015 Tel: +1(212) 584-4662.
Six-Step OB Ultrasound Abuhamad et al.

basic obstetric ultrasound examination that can be of signifi-

cant value to prenatal care and help identify pregnant women
in need of delivery at a facility equipped to manage compli-
cations. These six-step components include: (1) Fetal presen-
tation (cephalic, breech, other), (2) fetal cardiac activity (seen,
not seen), (3) presence of multiple pregnancy (yes, no), (4)
placental localization (normal, low-lying, previa), (5) amni-
otic fluid volume evaluation (normal, oligohydramnios, poly-
hydramnios), and (6) biometric measurements.
We have developed a standardized six-step approach to
perform these six components, which allows for simplifica-
tion of the obstetric ultrasound examination.1 Furthermore,
this standardized six-step approach has the potential to
enhance ultrasound training and competency assessment. Fig. 1 Initial transducer placement for determining fetal presentation
We have termed this standardized six-step approach to the (step 1). Note that the transducer was placed transversely in the lower
abdomen just above the symphysis pubis. This picture was taken from
obstetric ultrasound examination the “focused basic” obstet-
the patient’s left side. The dotted line represents the initial position
ric ultrasound examination. This study was designed to and orientation of the probe.
prospectively validate the focused basic obstetric ultrasound
examination and compare its performance to the scheduled
obstetric ultrasound examination.

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fetal head on the ultrasound monitor confirms a cephalic
presentation and the presence of fetal buttocks or lower
Materials and Methods
extremities confirms a breech presentation. Presence of
This prospective observational cohort study was approved by either a cephalic or a breech presentation implies a longitu-
the Institutional Review Board of Eastern Virginia Medical dinal lie of the fetus. If neither a cephalic nor a breech
School, and was undertaken at the Division of Maternal-Fetal presentation is noted, an oblique or transverse lie is inferred.
Medicine. After receiving written informed consent, a total of
200 consecutive women scheduled for ultrasound evaluation Step 2 Detection of Fetal Cardiac Activity
of fetal morphology or growth between 18þ0 and 36þ6 weeks The transducer is placed transversely in the lower abdomen
of gestation were enrolled in the study. Of them, 100 were just above the symphysis pubis, and is moved in the midabdo-
enrolled in the second trimester between 18þ0 and 27þ6 men toward the umbilicus while maintaining the transverse
weeks of gestation; and another 100 were enrolled in the orientation of the ultrasound transducer (►Fig. 2). If fetal
third trimester between 28þ0 and 36þ6 weeks of gestation. All cardiac activity is not seen following this initial step, the
ultrasound examinations were performed transabdominally transducer is moved from the midabdomen to the left and/or
using Voluson E8 (Expert edition) ultrasound equipment the right lateral side of the abdomen while maintaining the
(GE Healthcare Ultrasound, Milwaukee, WI). transverse orientation.
Before the routinely scheduled obstetric ultrasound exam-
ination, the six standardized steps of the focused basic
ultrasound examination were performed on each study pa-
tient by one investigator (Y. Z.) who is experienced in obstet-
ric ultrasound and blinded for any clinical information. The
total time for the ultrasound examination was calculated
along with the time spent on each of the six steps. The
time spent on each step was calculated by subtracting the
time showed on the last picture of corresponding step from
that of previous step. A picture was taken before starting step
1 as soon as the probe was placed on patient’s abdomen. The
focused basic ultrasound examination was performed by
following the exact steps outlined below by placing and
moving the transducer in a stepwise-predefined fashion.
The same investigator documented the ultrasound findings Fig. 2 Detection of fetal cardiac activity (step 2): The transducer was
after the examination was completed. The six standardized placed transversely in the lower abdomen just above the symphysis
steps are as follows: pubis, and was moved in the midabdomen toward the umbilicus while
maintaining the transverse orientation of the ultrasound transducer. If
fetal cardiac activity was not seen following this initial step, the
Step 1 Determination of Fetal Presentation
transducer was then moved from the umbilicus to the left and/or the
The ultrasound transducer is placed transversely in the lower right lateral side of the abdomen while maintaining the transverse
abdomen just above the patient’s symphysis pubis (►Fig. 1), orientation. The dotted line represents the initial position and orien-
and angled inferiorly toward the cervix. The presence of a tation of the probe.

American Journal of Perinatology


Fig. 3 Transverse transducer movement for determining number of
fetuses in uterine cavity (step 3 [part 1]). Note that the uterine cavity
was scanned from the symphysis toward the patient’s head along
tracks 1, 2, and 3, while maintaining the perpendicular orientation of
the transducer to the floor. The dotted line represents the initial
position and orientation of the probe for each maneuver.
Step 3 Identification of the Number of Fetuses in Uterus
The transducer is placed in a transverse orientation in the right
lower abdomen, and is moved cephalad toward the right upper
abdomen while maintaining the transverse orientation. The
same maneuver is repeated on the mid and left side of the
abdomen (►Fig. 3). The transducer is then placed in a sagittal
orientation in the right upper abdomen and moved toward the
left upper abdomen while maintaining the sagittal orientation.
This same maneuver is repeated in the lower abdomen (►Fig. 4).
The number of fetal heads (crania) within the uterus is then
identified. The presence of more than one fetal head implies the
presence of a multiple gestation. Care should be taken to keep
the transducer perpendicular to the floor and not tilted.
Step 4 Location and Position of the Placenta
The transducer is placed in the sagittal orientation in the right
upper abdomen, just above the uterine fundus and moved
toward the right lower abdomen while maintaining the same
Fig. 4 Initial sagittal transducer placement for determining number of
fetuses in uterine cavity (step 3 [part 2]). Note the sagittal placement
in the right upper abdomen and the perpendicular orientation of the
transducer to the floor. The transducer was moved from right to left
along tracks 1 and 2, while maintaining the perpendicular orientation
of the transducer to the floor. The dotted line represents the initial
position and orientation of the probe for each maneuver.
Six-Step OB Ultrasound Abuhamad et al.
Fig. 5 Sagittal transducer movement for determining placental
localization (step 4). Note that the uterine cavity was scanned from the
fundus toward the symphysis along tracks 1, 2, and 3 while main-
taining the transducer perpendicular to the floor. The dotted line
represents the initial position and orientation of the probe for each
maneuver.
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sagittal orientation. The same maneuver is repeated in the
mid and on the left side of the abdomen (►Fig. 5). If the lower
placental edge is suspected to be close to (< 2 cm from the
internal os of the cervix) or covering the cervix, then the
placental location will be double-checked transabdominally
during the scheduled obstetric ultrasound examination. If the
same finding is again suspected, the sonographer assigned for
the scheduled obstetric ultrasound examination will perform
a transvaginal ultrasound to confirm the presence or absence
of a placenta previa. The transvaginal ultrasound was not part
of the focused basic ultrasound in this study, as it was
assumed that it would be done as part of the scheduled
obstetric ultrasound examination when indicated.
Step 5 Estimating the Amniotic Fluid Volume
The four quadrants of the uterus are scanned with the
transducer in the sagittal orientation and perpendicular to
the floor (►Fig. 6). Measurement of the maximum vertical
Fig. 6 Sagittal transducer movement for amniotic fluid assessment
(step 5). Note that the uterine cavity was scanned from right lateral to
left lateral along tracks 1 to 2 and 3 to 4, while maintaining the
transducer in sagittal orientation and perpendicular to the floor. The
dotted line represents the position and orientation of the probe while
scanning the four different quadrants.
American Journal of Perinatology
Six-Step OB Ultrasound Abuhamad et al.
pocket (MVP) is then performed by placing the calipers in a
straight vertical line while avoiding any cord and fetal parts in
the image. Polyhydramnios is diagnosed when the MVP is
greater than or equal to 8 cm. Oligohydramnios is diagnosed
when the MVP is smaller than 2 cm.
Step 6 Fetal Biometric Measurements:
The biparietal diameter (BPD), head circumference, abdomi-
nal circumference (AC), and femur length are measured in the
traditional manner.2
Given that this represents the first study designed to
prospectively validate the focused basic obstetric ultrasound
examination (six-step) and compare its performance to the
standard obstetric ultrasound examination, the study opera-
tor who performed each of the six steps of the focused basic
ultrasound examination was skilled in the performance of
obstetrical ultrasound. As such, this study design does not
allow for the evaluation of competency in the performance of
the biometric measurements. It is understandable that step 6
of the focused basic ultrasound examination is the most
difficult step to teach as it requires standardized fetal planes
with appropriate caliper placement. Evaluating competency
of each of the six steps of the focused basic ultrasound
examination in health care workers with no prior ultrasound
training will be the subject of a future study.
Following performance of the focused basic ultrasound
examination, a registered sonographer who was blinded to
the results of the focused basic ultrasound examination
immediately performed the scheduled obstetric ultrasound
examination. How the scheduled examination was per-
formed was solely on that sonographer’s discretion. The
scheduled obstetric ultrasound examination consisted of
the morphologic evaluation of the fetus or assessment of
fetal growth. These ultrasound examinations complied with
the national guidelines for the performance of the obstetric
ultrasound examination as defined by American Institute of
Ultrasound in Medicine.2 If a low-lying placenta or placenta
previa was suspected in the scheduled obstetric ultrasound
examination, a transvaginal ultrasound examination was
performed to confirm the diagnosis.
To evaluate interobserver variability, saved still images (of
steps 3–4) and video clips (of steps 1–2) of the focused basic
examination from 30 pregnancies, selected at random (using
random number table, 15 cases for each trimester), were
reviewed and interpreted remotely by two reviewers (L. P., R.
R.) who are proficient in obstetric ultrasound and did not
participate in initial data acquisition.
Statistical Analysis
Statistical analysis was performed using the SPSS 15.0 soft-
ware (SPSS Inc., Chicago, IL) to compare the results derived
from the focused basic obstetric ultrasound and the sched-
uled obstetric ultrasound examinations. All continuous
variables were recorded as mean  standard deviation
(SD). The paired t-test was performed to compare continuous
variables between six-step and regular approaches, and an
independent t-test was performed to compare the time spent
on each step between the second and third trimesters.
American Journal of Perinatology
Ordinal variables (gravidity and parity) were recorded as
median (interquartile range). Mann–Whitney U test was
performed to compare ordinal data. Categorical data (race)
was compared using chi-square analysis. A p value less than
0.05 was considered statistically significant. The agreement
between the two approaches was evaluated by Cohen kappa
test (kappa value of greater than 0.40 is generally considered
good, with the higher value being better, the 95% confidence
interval of the kappa value was also calculated). The agree-
ment for continuous variables between the two approaches
was also evaluated by the coefficient of variation (CV).
CV (%) ¼ 100  SD/mean
P
SD ¼ √( [observer 1 observer 2]2/2N)
P
Mean ¼ (observer 1 þ observer 2)/2N
where, N was the total number of paired cases used in the
evaluation.
Results
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A total of 200 pregnant women were enrolled between
December 18, 2013 and May 2, 2014. The demographic
data of all enrolled pregnant women is listed in ►Table 1.
Body mass index (BMI) was calculated based on the measure-
ments from patient’s last visit before this study with docu-
mented height and weight. No significant differences were
present other than BMI (29.9 kg/m2 in the second trimester
vs. 32.1 kg/m2 in the third trimester, p < 0.05) between the
second and third trimester groups.
►Table 2 lists the time spent in seconds for each of the six
steps of the focused basic ultrasound examination in the
second and third trimester. The total time spent on the
focused basic ultrasound examination was significantly lon-
ger in the third trimester than that in the second trimester
(292.8 vs. 268.2 seconds, p < 0.001). The time spent on step 3
(30.2 vs. 27.4 seconds, p < 0.05) and step 6 (154.2 vs.
130.6 seconds, p < 0.001) was significantly longer in the
third trimester, while the time spent on step 5 was shorter
in the third trimester (38.3 vs. 41.7 seconds, p < 0.05). Over-
all, the average total time spent on focused basic ultrasound
examination was less than 5 minutes in both second and third
trimesters.
Comparison of each step performed by the six-step
approach and regular approach is listed in ►Tables 3
and 4. Agreement in step 2 and step 3 was not evaluated
due to lack of cases of fetal demise and multiple gestations
in this study population. Substantial to perfect agreement
was noted between the results derived from the focused
basic and scheduled obstetric ultrasound examinations for
steps 1, 4, 5, and 6 (the agreement of step 4 in the third
trimester was not evaluated due to the fact that no low-
lying placenta or placenta previa was suspected). Of the six
steps, step 1 had the best agreement between two ap-
proaches (kappa value ¼ 0.93 in the second trimester,
kappa value ¼ 0.95 in the third trimester). During step 2,
the focused basic obstetric ultrasound examination failed
to identify the heart beat in one case in the second
 Six-Step OB Ultrasound Abuhamad et al.

Table 1 Demographic data of pregnant women enrolled in the second and third trimester

Second trimester (N ¼ 100) Third trimester (N ¼ 100) p Value

Race (N of participants)
Caucasian 31 33 NS
Black 62 63 NS
Latino 3 4 NS
Asian 3 0 NS
Others 1 0 NS
Age (y) 27.4  6.4 28.1  5.7 NS
Gestational age (wk) 21.2  2.5 31.7  2.4 < 0.001
Gravidity 2 (3) 2 (3) NS
Parity 1 (1.25) 1 (2) NS
2
BMI (kg/m ) 29.9  7.4 32.1  8.8 < 0.05

Abbreviations: BMI, body mass index; NS, not significant.

Note: Age, gestational age, and BMI were presented as mean  SD. Gravidity and parity were presented as median (interquartile range). Independent
t-test was performed on continuous variables between two groups. Mann–Whitney U test was performed on ordinal variables. Chi-square analysis was
performed on categorical variables.

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trimester and two cases in the third trimester. Two of these
three cases had a transverse fetal lie, and the heart was
shadowed by the spine and upper extremity in the other
case with breech presentation. Of all continuous variables,
BPD had the best agreement (CV ¼ 1.8% in the second
trimester, CV ¼ 1.7% in the third trimester), while AC had
the worst (CV ¼ 3.5% in the second trimester, CV ¼ 2.7% in
the third trimester). The details for step 4 between the
focused basic obstetric ultrasound examination and the
scheduled obstetric ultrasound examination were listed
in ►Table 5.
Results from the remote review of the 30 randomly
selected cases matched the on-site review perfectly for steps
1 to 3 (100%). For step 4, placenta was described in the same
location on both the focused basic obstetric ultrasound
examination and the scheduled obstetric ultrasound exami-
nation in 26 cases (86.7%), meanwhile one mismatch in the
second trimester and three mismatches in the third trimester
were also noted (►Table 6).
Discussion
Introducing ultrasound to prenatal care has a considerable
positive impact on pregnancy outcomes. Ultrasound has been
shown to revise inaccurate dating, diagnose multiple gesta-
tions, identify placental and amniotic fluid abnormalities,
detect ectopic implantations and fetal malpresentation, all of
which are associated with increased risk for maternal or
neonatal morbidity and mortality.
Recently, there has been an increase in utilization of
obstetric ultrasound in limited resource settings around the
world with the goal of identifying high-risk pregnancies and
directing their care to hospital settings that are able to
manage pregnancy complications. The impact of introducing
ultrasound services to two hospitals in a limited resource
setting was evaluated in rural Rwanda.3 In this study, adult
women appeared to benefit most from the presence of
ultrasound services with obstetrical scanning being the
most frequently used application.3 Ultrasound changed

Table 2 Time (seconds) to complete each step of the standardized six-step approach to the ultrasound examination in the second
and third trimester

Second trimester (N ¼ 100) Third trimester (N ¼ 100) p Value

Step 1 (presentation) 15.9  8.7 14.9  4.5 NS
Step 2 (cardiac activity) 19.0  6.8 18.9  7.2 NS
Step 3 (number of fetus[es]) 27.4  11.2 30.2  8.5 < 0.05
Step 4 (placental localization) 33.6  14.1 33.3  17.0 NS
Step 5 (amniotic fluid) 41.7  17.1 38.3  13.3 < 0.05
Step 6 (biometry) 130.6  45.7 154.2  57.5 < 0.001
Total 268.2  64.4 292.8  65.2 < 0.001

Abbreviation: NS, not significant.

Note: Time was presented as mean  SD. Independent t-test was performed between two groups.

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Six-Step OB Ultrasound Abuhamad et al.

Table 3 Comparative data between the standardized six-step approach and the regular approach in the second trimester

Six-step approach (N ¼ 100) Regular approach (N ¼ 100) Kappa (95% CI)

Step 1
Fetal presentation Vertex Breech Others 0.93 (0.87–1.00)
Vertex 31 0 0
Breech 0 50 2
Others 2 0 15
Step 2
Heart activity Seen Not seen NAa
Seen 99 0
Not seen 1 0
Step 3
Number of fetus(es) Singleton Others NAa
Singleton 100 0
Others 0 0
Step 4

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Placental location Normal Low-lying placenta or previa 0.64 (0.36–0.93)
Normal 90 0
Suspected Low-lying or previa 5 5
Step 5
Amniotic fluid Normal Polyhydramnios Oligohydramnios 1.00 (1.00–1.00)
Normal 98 0 0
Polyhydramnios 0 2 0
Oligohydramnios 0 0 0
Measurement Six-step approach Regular approach Paired t-test CV
MVP (cm) 5.3  1.1 5.1  1.1 NS 14.4%
Step 6
BPD (cm) 5.1  0.8 5.1  0.8 NS 1.8%
HC (cm) 19.1  3.1 19.2  3.0 NS 1.9%
AC (cm) 17.2  3.0 16.9  3.0 NS 3.5%
FL (cm) 3.7  0.7 3.7  0.7 NS 2.5%

Abbreviations: AC, abdominal circumference; BPD, biparietal diameter; CI, confidence interval; CV, coefficient of variation; FL, femur length; HC, head
circumference; MVP, maximum vertical pocket; NS, not significant.
Note: Biometric measurements were presented as mean  SD. Data were compared between the six-step and regular approach, Cohen kappa test
was performed on the categorical variables, paired t-test was performed on continuous variables.
a
NA, not applicable, test could not be performed.

patient management in 43% of the cases with the most
common change being a planned surgical procedure.3 Fur-
thermore, sustainability of ultrasound was demonstrated
with posttraining scan reviews showing a high rate of con-
cordance in interpretation between the trainees and the
ultrasound quality review physicians.
Another study evaluated the diagnostic impact of limit-
ed obstetric ultrasound in identifying high-risk pregnan-
cies when used as a screening tool by midwives in rural
Uganda.4 The midwives in this study did not have any
ultrasound training before participating in a 6-week limit-
ed ultrasound-training course. 4 Midwife-performed
screening obstetric ultrasound, diagnosed twin gestations,
and fetal presentation with high sensitivity and specificity
and the ultrasound examination altered the clinical diag-
nosis in 12% of clinical encounters.4 Another study designed
to assess the intraobserver and interobserver agreement of
fetal biometry by locally trained health care workers in a
refugee camp in the Thai–Burmese border has shown
excellent correlation and suggests that locally trained
healthcare workers can obtain accurate fetal biometric
measurements. 5

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 Six-Step OB Ultrasound Abuhamad et al.

Table 4 Comparative data between the standardized six-step approach and the regular approach in the third trimester

Six-step approach (N ¼ 100) Regular approach (N ¼ 100) Kappa (95% CI)

Step 1
Fetal presentation Vertex Breech Others 0.95 (0.85–1.00)
Vertex 89 0 1
Breech 0 8 0
Others 0 0 2
Step 2
Heart activity Seen Not seen NAa
Seen 98 0
Not seen 2 0
Step 3
Number of fetus(es) Singleton Others NAa
Singleton 100 0
Others 0 0
Step 4

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Placental location Normal Low-lying placenta or previa NAa
Normal 99 0
Suspected low-lying or previa 1 0
Step 5
Amniotic fluid Normal Polyhydramnios Oligohydramnios 0.78 (0.55–1.00)
Normal 91 2 0
Polyhydramnios 1 6 0
Oligohydramnios 0 0 0
Measurement Six-step approach Regular approach Paired t-test CV
MVP (cm) 5.8  1.4 5.8  1.5 NS 11.5%
Step 6
BPD (cm) 8.0  0.6 8.0  0.6 NS 1.7%
HC (cm) 29.3  1.9 29.6  2.0 NS 2.3%
AC (cm) 28.3  2.7 28.0  2.9 NS 2.7%
FL (cm) 6.1  0.5 6.1  0.5 NS 1.9%

Abbreviations: AC, abdominal circumference; BPD, biparietal diameter; CI, confidence interval; CV, coefficient of variation; FL, femur length; HC, head
circumference; MVP, maximum vertical pocket; NS, not significant.
Note: Biometric measurements were presented as mean  SD. Data were compared between the six-step and regular approach, Cohen kappa test
was performed on the categorical variables, paired t-test was performed on continuous variables.
a
NA, not applicable, test could not be performed.

The implementation of successful ultrasound training
programs for local practitioners in limited resource settings
is essential to ensure competency of staff and sustainability
of ultrasound services. In 1998, the World Health Organi-
zation established standards in ultrasound training and
recommended that an appropriate curriculum be adopted
for the training of practitioners in the use of diagnostic
ultrasound.6 Despite this, there has been no standardized
approach to the curriculum. In addition, there is no defined
amount of time recommended for the length of training
and there are no mechanisms instituted to assess compe-
tency of trainees. Overall the available literature suggests
that a short but intensive training period is sufficient for
preparing clinical officers, nurses, and physicians alike to
perform basic ultrasound examinations, especially if the
training programs include both lectures and hands-on
practical training.7
In this study we present a standardized six-step approach to
the focused basic obstetric ultrasound examination, which
includes initial placement and movement of the transducer
in a predefined step-by-step fashion. To our knowledge, this
represents the first presentation of a standardized approach to
the focused basic ultrasound examination. The value of this
approach to ultrasound training is significant in that it clearly

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Six-Step OB Ultrasound Abuhamad et al.

Table 5 Data between the standardized six-step approach and the regular approach regarding placental location (step 4)

Six-step approach Regular approach

(N ¼ 100) (N ¼ 100)
Step 4 in the second trimester
Placental location
Anteriora 35 37
a
Posterior 42 48
a
Left lateral 4 2
a
Right lateral 3 3
Fundal 6 5
Low-lying suspected 5 3
Previa suspected 5 2
Step 4 in the third trimester
Placental location
Anteriora 50 46
Posteriora 35 37

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a
Left lateral 6 8
a
Right lateral 3 5
Fundal 5 4
Low-lying suspected 0 0
Previa suspected 1 0
a
Including anterior fundal, posterior fundal, or lateral fundal, respectively.

defines the technical components and ultrasound findings of
each of the six steps of the focused basic obstetric ultrasound
examination and substantially reduces the operator depen-
dency of obstetric sonography. Furthermore, by defining the
technical aspect and expected findings of each of the six steps
of the focused basic ultrasound examination, training of staff
and competency evaluation can be effectively performed. With
advancement in ultrasound automation and image recogni-
tion, this six-step approach to the basic obstetric ultrasound
examination holds great promise for ease of ultrasound train-
ing of healthcare workers and for enhanced accuracy in
diagnosis. Based upon our experience in ultrasound training
in limited resource settings, this standardized approach is easy
to learn and implement with high agreement.8
Our results showed high agreement between the focused
basic obstetric ultrasound examination and the scheduled ob-
stetric ultrasound examination. This finding is important as it
validates the concept of focused basic ultrasound examination, a
required initial phase before wide dissemination and implemen-
tation. There were some discrepancies in results however. There
were five out of 100 cases in the second trimester that were
suspected to have either a low-lying placenta or placenta previa
on step 4 of the focused basic examination; however, they were
confirmed to be normal on the scheduled scan. One possible
reason for this discrepancy is that we omitted the transvaginal
ultrasound step in the focused basic ultrasound examination and
thus could not further evaluate for a suspected low-lying
placenta. Despite that, no low-lying placenta or placenta previa
was missed during the focused basic ultrasound examination.
There were also some discrepancies in the evaluation of amniotic
fluid volume, which may be related to a change in fetal position
between examinations.

Table 6 Discrepancies regarding placental location (step 4) on the remote review of the 30 cases selected at random

Trimester On site reviewa Remote review

Case 1 Second Posterior Fundal
Case 2 Third Low-lying Anterior
Case 3 Third Posterior Fundal
Case 4 Third Posterior Low-lyingb
a
On site review results were based on scheduled obstetric ultrasound examinations, low-lying placenta was confirmed transvaginally.
b
After retrospective reviewing of the images, the placental location of this case was confirmed to be posterior.

American Journal of Perinatology


This standardized approach to the performance of the
focused basic ultrasound examination shows great potential
for incorporation into a telemedicine program. Accurate
remote reading of ultrasound images and clips is thus greatly
improved when standardized ultrasound steps are followed
in a pre-defined fashion. The acquisition of images and clips
from each of the six steps is standardized given that the
technical aspect of each of the six steps is well defined. As
images and clips are acquired in a standardized fashion, it can
help trainees avoid diagnostic errors. In additions, due to
standardization, remote review becomes feasible. This was
demonstrated in our results by the remote review of 30
randomly selected cases with excellent overall agreement
in image and clip interpretation. Remote review of images
and clips may prove to be of great help in the introduction and
sustainability of ultrasound training in limited resource
settings.
The average time for the performance of the focused basic
ultrasound examination was less than 5 minutes, a short time
compared with the routine ultrasound examination. This is
an important aspect of the focused basic ultrasound exami-
nation as it allows for easy incorporation in prenatal care in
short-staffed outreach settings.
Limitation of the Study
One of the limitations of our study is that it was performed in
a referral unit with the assumption that the results apply to
limited resource settings. Given that this represents the first
study comparing a six-step standardized approach of the
focused basic obstetric ultrasound examination to the regular
approach of the scheduled obstetric ultrasound examination,
our main goal was to ensure that this new approach was
validated in a clinical setting, as initial confirmation of the
accuracy of the focused basic ultrasound examination before
implementation.
Another limitation is that our study lacked pregnancies
with fetal demise and multiple gestations, which limited
our ability to assess steps 2 and 3. We could not control this
process as pregnancies were consecutively enrolled in this
study following informed consent. Furthermore, the study
design did not allow for assessment of step 6, which
includes biometric measurements as the operator perform-
ing the focused basic ultrasound examination had training
in ultrasound and this step is not standardized with regards
to transducer placement and movement on the maternal
abdomen. Several ultrasound equipment today has the
capability of automated biometric measurements,9 which
reduces substantially the operator dependency of step 6.
Assessing competency and skills of trainees with no prior
ultrasound training in the focused basic ultrasound exami-
nation will be part of a future study. Finally, the standard-
ized steps do not include review of fetal anatomy. This was
Six-Step OB Ultrasound Abuhamad et al.
done by design, as incorporating the fetal anatomy survey
in a focused basic ultrasound examination results in an
ultrasound examination that is difficult to teach in a short
focused training course. Furthermore, many facilities in
limited resource settings are not equipped to manage
pregnancies with complex fetal congenital malformations.
Based upon our experience, introducing anatomic assess-
ment of the fetus should be done after the trainees attain a
level of competency with the focused basic ultrasound
examination.
Conclusion
A six-step standardized approach to the focused basic ultra-
sound examination reduces the operator dependency of
ultrasound and has the potential to enhance ultrasound
training and competency evaluation in trainees with no prior
ultrasound training. This may be of substantial benefit to
ultrasound training in limited resource settings and as an
introductory training to obstetric ultrasonography for stu-
Downloaded by: University of Florida. Copyrighted material.
dents and residents in training programs.
Acknowledgments
None.
References
1 Abuhamad AZ, Chaoui R, Jeanty P, Paladini D. Ultrasound in
Obstetric and Gynecology: A Practical Approach. 1st ed. 2014:
186–211
2 American Institute of Ultrasound in Medicine. AIUM practice
guideline for the performance of obstetric ultrasound examina-
tions. J Ultrasound Med 2013;32(6):1083–1101
3 Shah SP, Epino H, Bukhman G, et al. Impact of the introduction of
ultrasound services in a limited resource setting: rural Rwanda
2008. BMC Int Health Hum Rights 2009;9:4
4 Swanson JO, Kawooya MG, Swanson DL, Hippe DS, Dungu-Matovu
P, Nathan R. The diagnostic impact of limited, screening obstetric
ultrasound when performed by midwives in rural Uganda.
J Perinatol 2014;34(7):508–512
5 Rijken MJ, Lee SJ, Boel ME, et al. Obstetric ultrasound
scanning by local health workers in a refugee camp on the
Thai-Burmese border. Ultrasound Obstet Gynecol 2009;34(4):
395–403
6 Training in diagnostic ultrasound: essentials, principles and
standards. Report of a WHO Study Group. World Health Organ
Tech Rep Ser 1998;875:i-46 back cover.
7 Sippel S, Muruganandan K, Levine A, Shah S. Review article: Use of
ultrasound in the developing world. Int J Emerg Med 2011;4:72
8 Abuhamad AZ. Ultrasound outreach and the crisis in Haiti.
J Ultrasound Med 2010;29(4):673–677
9 Yazdi B, Zanker P, Wanger P, et al. Optimal caliper placement:
manual vs automated methods. Ultrasound Obstet Gynecol 2014;
43(2):170–175
American Journal of Perinatology