Transvaginal ultrasound scanningRCN guidance for fertility nurses

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Contents

Introduction 3

Professional accountability 3

Requirements of the role 4

Following training protocols 4

Training guidance 6

� baseline scan 6

� follicular tracking 6

� downregulation scanning 7

� classification of polycystic ovarian syndrome 7

� multiple follicular ovaries 7

� early pregnancy ultrasound 8

� fetal heart beat 8

� empty gestational sac 8

� ectopic pregnancy 9

� nothing in utero 9

� multiple pregnancies 9

References and further reading 11

This guidance has been produced by the Royal College of NursingFertility Nursing Forum.

Transvaginal ultrasound scanning

RCN guidance for fertility nurses

This publication is due for review in January 2017. To provide feedback on itscontents or on your experience of using the publication, please emailpublications.feedback@rcn.org.uk

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Introduction

This guidance has been produced bythe RCN Fertility Nursing Forum, andis aimed at fertility nurses who carryout transvaginal ultrasound scans.

As a fertility nurse you are professionallyaccountable, and regularly reviewingyour work and maintaining yourcompetence is paramount. You mustensure that you have the appropriatetraining and experience to performtransvaginal ultrasound scans. Thisguidance outlines some of the key issuesthat you need to be aware of – not leastthe importance of good communicationwith women.

Professionalaccountability

The Code, published in 2010 by theNursing and Midwifery Council(NMC), clarifies the role of the nurseas: The Code is the foundation of goodnursing and midwifery practice, and akey tool in safeguarding the health andwellbeing of the public. The people inyour care must be able to trust youwith their health and wellbeing. Tojustify that trust you must:

� make the care of people your firstconcern, treating them as

individuals and respecting theirdignity

� work with others to protect andpromote the health and wellbeing ofthose in your care, their familiesand carers, and the widercommunity

� provide a high standard of practiceand care at all times

� be open and honest, act withintegrity and uphold the reputationof your profession.

As a professional, you are personallyaccountable for actions and omissionsin your practice and must always beable to justify your decisions. You mustalways act lawfully, whether those lawsrelate to your professional practice orpersonal life (NMC, 2010).

In particular you must ‘maintain andimprove your professional knowledgeand competence’ and ‘acknowledgeany limitations in your knowledge andcompetence and decline any duties orresponsibilities unless able to performthem in a safe and skilled manner’.

The NMC is clear that as anaccountable professional you must becompetent to carry out any activitythat expands your scope of practiceand under no circumstances shouldyou undertake a procedure unless you

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are competent to do so. It is yourresponsibility to inform your managerif you haven’t had appropriate training.

The nursing team should ensure that itis meeting current legislation, policiesand protocols set out by the NMC, RCNand employing authorities.Practitioners in the NHS andindependent sectors should complywith policies set by fertility unitmanagement, as well as health carestandards and the Human Fertilisationand Embryology Authority (HFEA)Code of practice.

Individual nurses should ensure thatthey have indemnity insurance from aprofessional organisation and thattheir employer should provideadequate vicarious liability for theiremployees.

Requirements of the role

In order to perform transvaginalultrasound scans you must:

� be a nurse or a midwife on the NMCregister with experience in women’shealth

� have achieved competent practice inall appropriate aspects of assistedreproductive techniques

� be able to demonstrate knowledgeof pelvic anatomy, physiology andpathology of the femalereproductive system

� follow HFEA regulations and allnational regulatory standards

� undertake courses to maintain safepractice including:

� proficiency in intravenous (IV)drug administration

� competency in cardiopulmonary resuscitation

� competency in cannulation.

Good communication is essentialduring the procedure as the womanmay feel vulnerable. Give a fullexplanation of what you are doing andwhy, using language that the womanunderstands.

You must also ensure that patientshave undergone a full consultation,completed local and HFEA consentforms, and had the recommendedscreening prior to treatment.

Following trainingprotocolsEach team should develop unitprotocols for all procedures performedby health care practitioners, whichshould be regularly updated.

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The protocols should cover:

� the location

� equipment required

� description of the procedure thateach practitioner should follow.

You must be able to demonstrateknowledge of ultrasound generationand detection that includes:

� sound wave motion and impedance

� pulse echo principle

� piezoelectric effect

� simple probe construction.

You must be able to demonstrateknowledge of ultrasound beams andselecting transducers that includes:

� axial and lateral resolution

� ultrasound beam shape

� focusing

� selecting transducers.

You must be able to demonstrate anunderstanding of acoustic output,biological interactions, hazards andsafety. For example:

� acoustic output parameters andmeasurement

� physical effects of ultrasound

� biological risks

� on screen indices

� imaging quality control

� infection control.

You must be able to demonstrate anunderstanding of:

� the causes and appearances ofartefacts

� calliper functions

� calculations

� error.

You must be able to demonstrate anunderstanding of transabdominal(TA) sonography and transvaginal(TV) sonography that includes:

� the scanning environment

� patient care

� TA techniques

� TV techniques

� terminology.

You must be able to demonstrate anunderstanding of propagation andattenuation in tissue that includes:

� important image formationinteractions

� interactions that degrade the image

� decibels

� attenuation.

Supervision should be mandatoryuntil you have been assessed ascompetent by a senior nurse or

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clinician. You must audit your practiceon a monthly basis, and ensure that itis regularly reviewed.You should alsokeep accurate records.

Training guidance

You may find that the followingsection is a useful aid prior tocompleting your training. But, first youmust be able to demonstrate anunderstanding of:

� anatomical features of the femalepelvis and their ultrasoundappearance

� embryology – awareness of keyevents in fetal development fromfertilisation to 12 weeks.

You must also be able to:

� explain to the woman whensignificant developments take placeand describe the ultrasoundappearance of the key events

� advise the woman on the availableand appropriate antenatal careand/or screening once dischargedfrom the unit.

Baseline scan

To carry out a baseline scan the uterusshould be examined from fundus tocervix in longitudinal (two

measurements) and transverse (onemeasurement) planes. You shouldassess its orientation, size, shape andechotexture. Note any pathology andtake an appropriate image.

� Examine the endometrium inlongitudinal and transverse planes,and record the measurement of itsmaximum thickness in longitudinalsection.

� Examine the ovaries in longitudinaland transverse planes, assess forsize, outline and appearance.Comment on the presence of anycysts or masses and document thenumber of antral follicles.

� Document all information in thewoman’s notes, and have themsigned by the person whoperformed the scan.

� Explain findings to the woman.

Follicular tracking

To carry out follicular tracking youshould:

� examine the uterus in both planesand measure the endometrialthickness as described in thebaseline scan procedure above

� examine the right and left ovary,identify the follicular yield andsystematically measure eachfollicle.This process involves taking

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two measurements of the follicle atits maximum diameter from top tobottom, and right to left. Add themeasurements together, and thendivide by two

� record all measurements on thefolliculargram starting with thelargest follicle to the smallest

� ensure that the folliculargram issigned off by the operator.

Downregulation scanning

To carry out downregulation scanningyou should:

� follow the above protocol for theuterus and ovaries

� identify both the ovaries and locateany potential cystic feature

� measure the cystic feature in bothplanes and take a three-waymeasurement as described in thebaseline scan

� take an image of the feature andrecord in the notes.

Classification of polycysticovarian syndrome

To determine the presence ofpolycystic ovarian syndrome (PCOS),you should look for:

� enlarged ovary

� multiple, small peripheralcysts/follicles (more than 10 cysts

of 2mm to 8mm)

� dense bright stroma

� unilateral or bilateral features.

Multiple follicular ovaries

If you note multiple small folliclesdistributed throughout the ovarianstroma (more than 10 follicles of 2mm to 8mm), and there are no otherclassical PCOS features you shoulddescribe the ovaries as multi-follicular.

Typical sonographic features of asimple cyst:

� anechoic i.e. no solid components

� unilocular

� thin walled i.e. less than 3mm withno papillary projections.

Typical sonographic features thatsuggest malignancy:

� size: this tends to be larger thanbenign lesions, although earlylesions will be small and wellcontained in the ovary

� complexity: malignancies tend tobe more complex than benignlesions. Simple cystic ovariancarcinomas are rare but can occur

� cyst walls: they tend to be thickenedi.e. greater than 3mm, haveirregular contours and may have

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papillary projections into the cystitself

� intracystic septations

� solid elements

� mixed echogenicity cyst fluid

� ascites (excess fluid in theperitoneal cavity)

� blood flow characteristics: bloodflow can easily be detected in themajority of malignancies. It canshow typical low resistance flowwith pulsed wave Doppler.

Early pregnancy ultrasound

To carry out an ultrasound in earlypregnancy you should:

� ensure the woman is correctlyidentified according to unitprotocol

� assess the pelvis: size of the ovaries,any free fluid in the pelvis

� assess the uterus for presence ofgestation and numbers, shape, size,and identify yolk sac, fetal heartand monozygosity (predispositionto produce identical twins).

The outcomes of the scan will show:

� presence of fetal heart in sac(s) inutero

� sac in utero but no fetal heart orechoes clear in sac

� nothing in utero.

Fetal heart beat

If you find a fetal heart beat youshould:

� measure the crown-rump length(CRL). This is the maximumunflexed length of the embryo/fetusfrom crown to rump. Use the meanof three measurements. It isaccurate for dating to within +/-five days in the first trimester

� arrange a further scan for eightweeks gestation ie two weeks later

� send a letter to the woman’s GP.

Empty gestational sac

To determine whether the gestationalsac is empty, carry out the followinggestational sac volume calculation by:

� measuring the largestanteroposterior (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 Ldiameters (in cm) x 0.5233

� record all measurements in mms.

If you find that the woman’sgestational sac is empty you should:

� advise the woman that if there is nofetal heart beat at this stage, thiscan mean the pregnancy has ended.

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Ectopic pregnancyThe woman may have an ectopicpregnancy if your ultrasound findingsinclude:

� thickened endometrium

� free pelvic fluid

� adnexal mass and/or embryo/fetusand/or a heart beat

� a pseudosac visible in the uterinecavity.

Nothing in utero

If you find that there is nothing uteroafter a positive pregnancy test, andwhen there has been no bleeding orspotting, the woman may have abiochemical or ectopic pregnancy. Youshould:

� confirm your diagnosis by referringthe woman to a medicalpractitioner

� arrange a scan either with aqualified member of staff or inultrasound department

� take blood test for beta HCG andperform serial readings

� send a letter to your the woman’sGP.

You may find these symptomsassociated with ectopic pregnancy:

� lower abdominal pain often

associated with discomfort fromtransvaginal TV scanning

� vaginal bleeding

� light-headedness or dizziness

� shoulder tip pain.

Multiple pregnancies

Multiple pregnancy can be a high-riskcondition for a woman. You shouldidentify this condition in the firsttrimester of the pregnancy byultrasound scan.

Identical twins can be identified bydetermining chorionicity (separateplacentas). Examine the base of themembrane between the two sacs, andif you can see the placenta in the baseof the membrane between the two sacs– the lambda sign (the triangularshape where the membranes meet thetwo placentas) – then the pregnancy isdichorionic (non-identical twins). Ifyou cannot see the lambda sign, thepregnancy is probably monochorionic(when twins – often identical – share aplacenta and there is a T shape wherethe membranes meet the placenta).

Monochorionic pregnancies have apoorer outlook than dichorionicpregnancies, and are at risk ofdeveloping twin-to-twin transfusionsyndrome (TTTS). This occursbecause twins share a placenta, and a

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blood supply. One twin receives toomuch blood and becomes overloadedwith fluid, putting a strain on its heart.The other twin gets too little bloodand may not grow very well.Thishappens in about 10 per cent to 15 percent of all monochorionic twinpregnancies.

Action

If the woman is diagnosed with amultiple pregnancy you should:

� inform the woman and ensureappropriate support is availableshould she need to discuss thisfurther

� refer her immediately forappropriate antenatal care ensuringshe is aware of where her localmidwifery services are and how shecan contact a midwife.

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References

Human Ferilisation an EmbryologyAuthority (2013) Code of practice (8thed.), HFEA: London.

Loughna, P et al. (2009) Fetal size anddating: charts recommended forclinical obstetric practice, Ultrasound,August 2009, 17, 3. Available from:http://www.bmus.org/policies-guides/23-17-3-161_ultBMUS.pdf

National Institute for Health and CareExcellence (2013) Clinical guideline –Fertility: assessment and treatment forpeople with fertility problems, NMC:London. Available from:http://guidance.nice.org.uk/CG156

Nursing and Midwifery Council(2010) The Code, NMC: London.Available from: http://www.nmc-uk.org/Nurses-and-midwives/Standards-and-guidance1/The-code/The-code-in-full/

Royal College of Nursing (2012) AnRCN training and educationframework for fertility nursing, RCN:London. Publication code 004 322.Available from: www.rcn.org.uk

Royal College of Nursing (2011)Competences: Specialist competencesfor fertility nurses, RCN: London.Publication code 003 135. Availablefrom: www.rcn.org.uk

Further reading

British Medical Ultrasound Societyhttp://www.bmus.org/intro/home.asp

The RCN represents nurses and nursing, promotesexcellence in practice and shapes health policies

February 2014

Review date February 2017

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