Systematic introduction of obstetric ultrasound skills into practice

Objective: To identify the present skill level of obstetric ultrasound, to set quality standards and to make recommendations in terms of obstetrics ultrasound service improvement. Methods: An audit was carried out in five provinces in Sri Lanka. At the beginning of the ultrasound workshops, attendees were requested to participate in this audit. Optimum ultrasound machine settings and biometry standards were defined at the beginning. Measures were taken to recruit a cross section of the obstetric service providers including postgraduate trainees and senior house officers (SHOO). They were asked to perform an ultrasound scan and obtain standard images. These images were assessed onsite and documented in structured data sheet. The level of competency was analyzed according to the pre-defined standards. A structured ultrasound training programs have been carried out to improve the existing knowledge and skills of the participants. In order to simulate their own scan environment and habits, participants were assessed without their knowledge in the second phase of this audit. Results: Overall skills in controlling machine settings were very poor. Almost all the participants did not manage to set the machine competently. Postgraduates were slightly better in obtaining correct landmarks for fetal biometry. It is encouraging to note that most of the postgraduates were able to improve their machine setting skills in subsequent audit. First trimester crown-rump length is the least improved fetal biometry in second phase. Conclusion: At present background skills of obstetric ultrasound are substandard and it can be improved by dedicated training. Systematic Systematic introduction of obstetric ultrasound skills into practice Tiran Dias1, Lahiru Ruwanpura2 Sri Lanka Journal of Obstetrics and Gynaecology 2011; 33: 154-157 1 Research Fellow in St George’s University of London Fetal Medicine Unit St George’s University of London SW17 0QT London. 2 Research Assistant, Faculty of Medicine, University of Colombo, Sri Lanka. Correspondence: Tiran Dias E-mail: thiran_dias@yahoo.com introduction of obstetric ultrasound training in to post graduate training is necessary. This will produce a new generation of obstetricians competent in this field. All the newly appointed SHOO/MOO in obstetrics need to undergo mandatory training in obstetric ultrasound. Introduction Obstetric ultrasound has now become routine practice in antenatal care. It covers a spectrum of services ranging from antenatal screening for chromosomal aneployides to prediction of adverse outcomes in later pregnancy. Importance of first trimester ultrasound has been widely recognized and most countries have incorporated this practice to their guidelines and offer routine dating and screening for their antenatal population1-5 (Table 1). Country Timing of the Purpose of Scan the Scan United Kingdom 11-14 Dating 20-24 Anomaly screen Portugal and Italy 11-14 Dating 21-23 Anomaly Scan 32-34 Growth scan New Zealand 11-14 Dating and NT 20-22 Anomy scan >41 Post date assessment India No universal policy Table 1. Use of ultrasound in antenatal care in different countries In order to introduce routine obstetrics ultrasound scanning into the national antenatal policy, it is mandatory to have competent doctors in this field throughout the country. However, there is no systematic obstetric ultrasound training program in Sri Lanka. The need for such a program has long been awaited. In order to plan and implement a new program it is important to assess the existing ultrasound skills in obstetrics care givers.


Introduction
Obstetric ultrasound has now become routine practice in antenatal care.It covers a spectrum of services ranging from antenatal screening for chromosomal aneployides to prediction of adverse outcomes in later pregnancy.Importance of first trimester ultrasound has been widely recognized and most countries have incorporated this practice to their guidelines and offer routine dating and screening for their antenatal population [1][2][3][4][5]

Objective
The objective of this audit is to identify the present skill level of obstetric ultrasound, to set standards of quality, and give recommendations to Postgraduate Institute of Medicine (PGIM), Sri Lanka College of Obstetricians and Gynaecologists (SLCOG), Sri Lanka Obstetric Ultrasound Group (SLOUG) to work out a plan to improve this service.

Methodology Phase 1
This audit was carried out in five provinces in Sri Lanka with the collaboration of SLCOG and SLOUG.In view of teaching/ assessment and audit of obstetric ultrasound skills, five obstetric ultrasound workshops were organized in Galle, Colombo, Kurunegalla, Jaffna, and Badulla.At the beginning of these workshops attendees were requested to participate in this audit and following standards were defined at the beginning.
Ultrasound machine settings: Optimum use of recognized machine setting tools (probe orientation, presets, depth, frequency, gain, focus, frame rate and zoom) were assessed 6 .The candidates were requested to freeze the ultrasound image when they think image is optimum.The competency was categorized in to three levels in terms of their use (competent use, some use, no use).
Fetal biometry: The candidates were expected to acquire ultrasound images of fetal head, abdomen and mid-sagiital section in order to measure the head circumference (HC), abdominal circumference (AC) and the crown-rump length (CRL) respectively.Standards were set according to the established guidelines and competency was assessed in terms of use of correct landmarks 6 .
Measures were taken to recruit a cross section of participants including postgraduate trainees and senior house officers (SHOO) for this audit.They were asked to perform an ultrasound scan and obtain standard images.These images were assessed onsite and documented in structured data sheet.The level of competency was analyzed according to the predefined standards 6 .In view of upgrading present competency level, series of ultrasound training programs were conducted.In parallel with these workshops hands-on program was conducted by the SLOUG members and comprehensive practical hand book was distributed among participants.

Phase 2
In order to assess the improvement of obstetrics ultrasound skills and the progress of these training programs, re-audit was conducted in Colombo.Postgraduate trainees who attended the earlier workshops were reassessed in this second phase.In order to simulate their own scan environment and habits, participants were assessed without their knowledge.Same standards were used to assess the competency as described above 6 .

Results
A total of 21 candidates participated in this audit, out of which 10 were SHOO, 6 were postgraduate trainees and the rest were consultants, RHOO and MOO.Overall ultrasound machine settings were poor in both SHOO and postgraduate trainees (Figure 1, 2).Even though the general competency in fetal biometry is poor in all candidates, postgraduates were slightly better in taking fetal biometry than SHOO (Figure 3, 4).Four out of 6 postgraduate trainees who attended the first audit cycle were reassessed.It is encouraging to observe that most of the postgraduate trainees were able to improve their machine setting skills in subsequent audit (Figure 5).Optimum image for fetal HC measurement has been improved in terms of caliper placement (Figure 6).First trimester crown-rump length is the least improved fetal biometry in second phase.

Figure 5 .Figure 6 .
Figure 5. Ultrasound machine setting skills among Postgraduate trainees in obstetrics after the awareness program (completion of the cycle).

Table 1 . Use of ultrasound in antenatal care in different countries
(Table1).The need for such a program has long been awaited.In order to plan and implement a new program it is important to assess the existing ultrasound skills in obstetrics care givers.