Read Performing transvaginal ultrasound scanning text version

ROYAL COLLEGE OF N URSI NG

Performing transvaginal ultrasound scanning

RCN guidance for fertility nurses

ROYAL COLLEGE OF N URSI NG

Performing transvaginal ultrasound scanning

RCN guidance for fertility nurses Contents

Introduction Professional accountability Requirements of the role Following training protocols Training guidance

baseline scan follicular tracking downregulation scanning classification of polycystic ovarian syndrome multiple follicular ovaries early pregnancy ultrasound fetal heart beat empty gestational sac ectopic pregnancy nothing in utero multiple pregnancies

2 2 3 3 4 5 5 5 6 6 6 7 7 7 8 8 9

References This guidance has been produced by the Royal College of Nursing Fertility Nurses Group

1

P E R F O R M I N G T R A N S VA G I N A L U LT R A S O U N D S C A N N I N G

Introduction

This guidance has been produced by the RCN Fertility Nurses Group, and is aimed at fertility nurses who carry out transvaginal ultrasound scans. As a fertility nurse you are professionally accountable, and regularly reviewing your work and maintaining your competence is paramount.You must ensure that you have the appropriate training and experience to perform transvaginal ultrasound scans. This guidance outlines some of the key issues that you need to be aware of ­ not least the importance of good communication with patients.

responsibilities unless able to perform them in a safe and skilled manner'. The NMC suggests that if you are aware of your professional accountability, and competent to carry out an activity, then you can expand your scope of practice.However, under no circumstances should you undertake a procedure unless you are competent to do so. It is your responsibility to inform your manager if you haven't had appropriate training. Nurses should be able to access recognised courses in ultrasound. The nursing team should ensure that it is meeting current legislation, policies and protocols set out by the NMC, RCN and NHS trust boards. Practitioners in the NHS and independent sectors should comply with policies set by fertility unit management, as well as Healthcare Commission standards and the Human Fertilisation and Embryology Authority (HFEA) Code of practice. Individual nurses should ensure that they have indemnity insurance from a professional organisation such as the RCN, and that their employer gives vicarious liability to its employees.

Professional accountability

The Nursing and Midwifery Council's (NMC) Code of professional conduct (2004) states that `as a registered nurse, midwife or health visitor, you are professionally accountable for your practice'. In particular you must `maintain and improve your professional knowledge and competence' and `acknowledge any limitations in your knowledge and competence and decline any duties or

2

ROYAL COLLEGE OF N URSI NG

Requirements of the role

In order to perform transvaginal ultrasound scans you must: be a nurse or a midwife on the NMC register with experience in women's health have achieved competent practice in all appropriate aspects of assisted reproductive techniques be able to demonstrate knowledge of pelvic anatomy, physiology and pathology of the female reproductive system follow HFEA regulations and Healthcare Commission national standards undertake all trust/unit courses to maintain safe practice including: intravenous (IV) drug administration cardio pulmonary resuscitation cannulation. Good communication is essential during the procedure as the woman may feel vulnerable. Give a full explanation of what you are doing and why, using language that the woman understands.

3

You must also ensure that patients have undergone a full consultation, filled out your unit's and HFEA consent forms, and had the recommended screening prior to treatment.

Following training protocols

Each team should develop unit protocols for all procedures performed by health care practitioners, which should be regularly updated. The protocols should cover: the location equipment required description of the procedure that each practitioner should follow. You must be able to demonstrate knowledge of ultrasound generation and detection that includes: sound wave motion and impedance pulse echo principle piezoelectric effect simple probe construction. You must be able to demonstrate knowledge of ultrasound beams and selecting transducers that includes: axial and lateral resolution

P E R F O R M I N G T R A N S VA G I N A L U LT R A S O U N D S C A N N I N G

ultrasound beam shape focusing selecting transducers. You must be able to demonstrate an understanding of acoustic output, biological interactions, hazards and safety. For example: acoustic output parameters and measurement physical effects of ultrasound biological risks on screen indices imaging quality control infection control. You must be able to demonstrate an understanding of: the causes and appearances of artefacts calliper functions calculations error. You must be able to demonstrate an understanding of transabdominal (TA) sonography and transvaginal (TV) sonography that includes: the scanning environment patient care TA techniques

4

TV techniques terminology. You must be able to demonstrate an understanding of propagation and attenuation in tissue that includes: important image formation interactions interactions that degrade the image decibels attenuation. Supervision should be mandatory until you have been assessed as competent by a senior nurse or clinician.You must audit your practice on a monthly basis, and ensure that it is regularly reviewed.You should also keep accurate records.

Training guidance

You may find that the following section is a useful aid prior to completing your training.But, first you must be able to demonstrate an understanding of: anatomical features of the female pelvis and their ultrasound appearance embryology ­ awareness of key events in fetal development from fertilisation to 12 weeks.

ROYAL COLLEGE OF N URSI NG

You must also be able to: explain to the patient when significant developments take place and describe the ultrasound appearance of the key events advise the patient on the available and appropriate antenatal care and screening once discharged from the unit. Baseline scan To carry out a baseline scan the uterus should be examined from fundus to cervix in longitudinal (two measurements) and transverse (one measurement) planes.You should assess its orientation, size, shape and echotexture. Note any pathology and take an appropriate image.

Examine the endometrium in

signed by the person who performed the scan.

Explain findings to the patient.

longitudinal and transverse planes, and record the measurement of its maximum thickness in longitudinal section.

Examine the ovaries in longitudinal

Follicular tracking To carry out follicular tracking you should: examine the uterus in both planes and measure the endometrial thickness as described in the baseline scan procedure above examine the right and left ovary, identify the follicular yield and systematically measure each follicle.This process involves taking two measurements of the follicle at its maximum diameter from top to bottom, and right to left.Add the measurements together, and then divide by two record all measurements on the folliculargram starting with the largest follicle to the smallest ensure that the folliculargram is signed off by the operator. Downregulation scanning To carry out downregulation scanning you should: follow the above protocol for the uterus and ovaries identify both the ovaries and locate any potential cystic feature

5

and transverse planes, assess for size, outline and appearance. Comment on the presence of any cysts or masses and document the number of antral follicles.

Document all information in the

patient's notes, and have them

P E R F O R M I N G T R A N S VA G I N A L U LT R A S O U N D S C A N N I N G

measure the cystic feature in both

planes and take a three-way measurement as described in the baseline scan take an image of the feature and record in the notes. Classification of polycystic ovarian syndrome To determine the presence of polycystic ovarian syndrome (PCOS), you should look for:

enlarged ovary multiple, small peripheral

Typical sonographic features that suggest malignancy:

size: this tends to be larger than

cysts/follicles (more than 10 cysts of 2 mm to 8 mm) dense bright stroma unilateral or bilateral features. Multiple follicular ovaries If you note multiple small follicles distributed throughout the ovarian stroma (more than 10 follicles of 2 mm to 8 mm), and there are no other classical PCOS features you should describe the ovaries as multi-follicular. Typical sonographic features of a simple cyst:

anechoic i.e. no solid components unilocular thin walled i.e. less than 3 mm with

benign lesions, although early lesions will be small and well contained in the ovary complexity: malignancies tend to be more complex than benign lesions. Simple cystic ovarian carcinomas are rare but can occur cyst walls: they tend to be thickened i.e. greater than 3 mm, have irregular contours and may have papillary projections into the cyst itself intracystic septations solid elements mixed echogenicity cyst fluid ascites (excess fluid in the peritoneal cavity) blood flow characteristics: blood flow can easily be detected in the majority of malignancies. It can show typical low resistance flow with pulsed wave Doppler. Early pregnancy ultrasound To carry out an ultrasound in early pregnancy you should:

ensure the patient is correctly is

no papillary projections.

6

correctly identified according to unit protocol

ROYAL COLLEGE OF N URSI NG

assess the pelvis: size of the ovaries,

measuring the largest

any free fluid in the pelvis assess uterus for presence of gestation and numbers, shape, size, and identify yolk sac, fetal heart and monozygosity (predisposition to produce identical twins). The outcomes of the scan will show: presence of fetal heart in sac(s) in utero sac in utero but no fetal heart or echoes clear in sac nothing in utero. Fetal heart beat If you find a fetal heart beat you should:

measure the crown-rump length

anteroposterior (A-P), transverse (T) and longitudinal (L) measurement of the gestational sac calculating the volume as follows: sac volume (ml) = A-P x T x L diameters (in cm) x 0.5233 record all measurements in mm. If you find that the patient's gestational sac is empty you should:

advise the patient that if there is no

(CRL). This is the maximum unflexed length of the embryo/fetus from crown to rump.Use the mean of three measurements. It is accurate for dating to within +/- 5 days in the first trimester arrange scan for 8 weeks gestation i.e. 2 weeks later send a letter to the patient's GP. Empty gestational sac To determine whether the gestational sac is empty, carry out the following gestational sac volume calculation by:

7

fetal heart beat at this stage, this can mean the pregnancy has ended if you are unsure, ask an experienced operator to scan re-scan in 7 days, and if there is no change consult the doctor for further management arrange follow-up appointment with the patient to discuss the outcome send a letter to the patient's GP. Ectopic pregnancy Your patient may have an ectopic pregnancy if your ultrasound findings include:

thickened endometrium free pelvic fluid adnexal mass and/or embryo/fetus

and/or a heart beat a pseudosac visible in the uterine cavity.

P E R F O R M I N G T R A N S VA G I N A L U LT R A S O U N D S C A N N I N G

Nothing in utero If you find that there is nothing in utero after a positive test, and when there has been no bleeding or spotting, your patient may have a biochemical or ectopic pregnancy.You should:

confirm your diagnosis by referring

the patient to a medical practitioner arrange a scan either with qualified member of staff or in ultrasound department take blood test for beta HCG and perform serial readings send a letter to your patient's GP. You may find these symptoms associated with ectopic pregnancy:

lower abdominal pain often

membrane between the two sacs, and if you can see the placenta in the base of the membrane between the two sacs ­ the lambda sign (the triangular shape where the membranes meet the two placentas) ­ then the pregnancy is dichorionic (non-identical twins). If you cannot see the lambda sign, the pregnancy is probably monochorionic (when twins ­ often identical ­ share a placenta and there is a T shape where the membranes meet the placenta). Monochorionic pregnancies have a poorer outlook than dichorionic pregnancies, and are at risk of developing twin-to-twin transfusion syndrome (TTTS). This occurs because twins share a placenta, and a blood supply. One twin receives too much blood and becomes overloaded with fluid, putting a strain on its heart. The other twin gets too little blood and may not grow very well.This happens in about 10 per cent to 15 per cent of all monochorionic twin pregnancies. Action If a patient has a multiple pregnancy you should:

inform the patient refer the patient for appropriate

associated with discomfort from TV scanning vaginal bleeding light-headedness or dizziness shoulder tip pain. Multiple pregnancies Multiple pregnancy can be a high-risk condition for a patient.You should identify this condition in the first trimester of the pregnancy by ultrasound scan. Identical twins can be identified by determining chorionicity (separate placentas). Examine the base of the

8

antenatal care.

ROYAL COLLEGE OF N URSI NG

References

British Medical Ultrasound Society (1990) Fetal Measurements Working Party. Clinical applications of ultrasonic fetal measurements (p.5), London: British Institute of Radiology. Nursing and Midwifery Council (2004) Code of professional conduct, London: NMC.Available from: www.nmc-uk.org Nursing and Midwifery Council (2001) Standards for specialist education and practice, London:NMC. National Institute for Clinical Excellence (2004) Clinical guideline 11. Fertility: assessment and treatment for people with fertility problems, London: NICE.Available from: www.nice.org.uk

9

February 2006 Published by the Royal College of Nursing 20 Cavendish Square London W1G 0RN 020 7409 3333 The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies

Publication code 002 795

Information

Performing transvaginal ultrasound scanning

12 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

1318238