Special Report ajog.

org

Obstetric and gynecologic ultrasound curriculum

and competency assessment in residency
training programs: consensus report
Alfred Abuhamad, MD; Katherine K. Minton, MA, RDMS, RDCS; Carol B. Benson, MD;
Trish Chudleigh, PhD; Lori Crites, BS, RDMS; Peter M. Doubilet, MD, PhD; Rita Driggers, MD;
Wesley Lee, MD; Karen V. Mann, MD; James J. Perez, DO; Nancy C. Rose, MD;
Lynn L. Simpson, MD; Ann Tabor, MD; Beryl R. Benacerraf, MD

Introduction
Ultrasound imaging is integral to the
practice of obstetrics and gynecology, as it
allows comprehensive anatomic and
physiologic evaluation of the fetus and
detailed assessment of the maternal pelvic
organs. Ultrasound imaging has signifi-
cant advantages over other imaging mo-
dalities. The technology is portable, is
relatively inexpensive, and does not
involve ionizing radiation. In the gyneco-
logic patient, the real-time aspect of this
modality allows the operator to use
transducer pressure to palpate as the pa-
tient is imaged, thus localizing
the anatomic source of pelvic pain, and to
examine for the sliding of organs over each
other and over the pelvic wall. Ultrasound
imaging is also used widely in obstetrics,
with current data suggesting that pregnant
women in the United States receive on
average about 4.5 ultrasound examina-
tions per pregnancy.1
To a much greater extent than
computed tomography or magnetic
resonance imaging, ultrasound imaging
is operator-dependent. Adequate
Ultrasound imaging has become integral to the practice of obstetrics and gynecology. With
increasing educational demands and limited hours in residency programs, dedicated time for
training and achieving competency in ultrasound has diminished substantially. The American
Institute of Ultrasound in Medicine assembled a multisociety task force to develop a consensus-
based, standardized curriculum and competency assessment tools for obstetric and gyneco-
logic ultrasound training in residency programs. The curriculum and competency assessment
tools were developed based on existing national and international guidelines for the perfor-
mance of obstetric and gynecologic ultrasound examinations and thus are intended to represent
the minimum requirement for such training. By expert consensus, the curriculum was devel-
oped for each year of training, criteria for each competency assessment image were generated,
the pass score was established at, or close to, 75% for each, and obtaining a set of 5 ultrasound
images with pass score in each was deemed necessary for attaining each competency.
Given the current lack of substantial data on competency assessment in ultrasound training,
the task force expects that the criteria set forth in this document will evolve with time. The
task force also encourages use of ultrasound simulation in residency training and expects
that simulation will play a significant part in the curriculum and the competency assessment
process. Incorporating this training curriculum and the competency assessment tools may
promote consistency in training and competency assessment, thus enhancing the perfor-
mance and diagnostic accuracy of ultrasound examination in obstetrics and gynecology.
Key words: quality control, residency programs, simulation, sonographic images, ultrasound
competency, ultrasound curriculum, ultrasound training
technical skills and a good understand- examination. The quality of ultrasound
ing of anatomy are essential to the images is dependent on several factors,
performance of the ultrasound including the operator having a basic

From the Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Dr Abuhamad); American Institute of Ultrasound in
Medicine, Laurel, MD (Ms Minton); Department of Radiology, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA (Drs Benson,
Doubilet and Benacerraf); Department of Ultrasound, Cambridge University Hospitals, Cambridge, United Kingdom (Dr Chudleigh); Ultrasound
Education, Obstetrics and Gynecology Residency Program, Doctors Hospital OhioHealth, Columbus, OH (Ms Crites and Dr Perez); Department of
Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, MD (Dr Driggers); Department of Obstetrics and Gynecology, Division of Women’s and
Fetal Imaging, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX (Dr Lee); Division of Medical Education, Dalhousie University,
Halifax, Nova Scotia, Canada (Dr Mann); Reproductive Genetics, Intermountain Healthcare, Department of Obstetrics and Gynecology, University of
Utah, Salt Lake City, UT (Dr Rose); Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY (Dr Simpson); and
Department of Obstetrics, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark (Dr Tabor).
Disclosure: W.L. received honoraria from GE Healthcare as a faculty speaker, and limited research funding from Samsung. N.C.R. received support from
the National Institutes of Health as an investigator; honoraria for an ethics grant in prenatal development from the Hastings Center for Bioethics; and
compensation from the Texas Department of Health for lecture series for circulating cell-free DNA. The remaining authors report no conflicts of interest.
This paper is being simultaneously published in American Journal of Obstetrics & Gynecology, Journal of Ultrasound in Medicine, and Ultrasound in
Obstetrics and Gynecology.
Corresponding author: Alfred Abuhamad, MD. abuhamaz@evms.edu
0002-9378/$36.00
ª 2017 jointly by the International Society of Ultrasound in Obstetrics and Gynecology, the American Institute of Ultrasound in Medicine, and Elsevier
Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2017.10.016

JANUARY 2018 American Journal of Obstetrics & Gynecology 29

Special Report
understanding of ultrasound physics and
familiarity with the ultrasound machine
control panel, as well as on their skills
and competency in performing the ex-
amination. Obstetric ultrasound imag-
ing is particularly challenging, given the
small size of fetal organs and the variable
fetal position in the uterus, which occa-
sionally obscures target anatomic
regions.
With the increasing educational de-
mands and limited hours in residency
training programs, dedicated time for
training and achieving competency in
ultrasound has diminished substantially.
Data from the Accreditation Council for
Graduate Medical Education on ultra-
sound performance in obstetric and gy-
necologic residency programs indicate
that currently the number of ultrasound
procedures performed as part of many
training programs falls short of the
minimum threshold required for physi-
cian qualification for the performance of
obstetric and gynecologic ultrasound
examinations, as defined by the Amer-
ican Institute of Ultrasound in Medicine
(AIUM).2,3
Given the clinical importance and
widespread use of ultrasound imaging in
obstetrics and gynecology, the AIUM
assembled a multisociety task force to
develop a standardized consensus-based
curriculum and competency assessment
tools for the performance of the basic
obstetric and gynecologic ultrasound
examination, intended to be used in
residency programs. Task force partici-
pants included representatives from the
AIUM, Society for Maternal-Fetal Med-
icine (SMFM), American Congress of
Obstetricians and Gynecologists
(ACOG), American College of Osteo-
pathic Obstetricians and Gynecologists
(ACOOG), American College of Radi-
ology (ACR), International Society of
Ultrasound in Obstetrics and Gynecol-
ogy (ISUOG), and Society of Radiolo-
gists in Ultrasound (SRU).
Procedure: curriculum and
competency development
The process of developing the document
included multiple telephone conference
calls and one face-to-face meeting be-
tween members of the task force. The
30 American Journal of Obstetrics & Gynecology JANUARY 2018
curriculum was developed based on
existing national and international
guidelines for the performance of ob-
stetric and gynecologic ultrasound ex-
amination4-6 and is intended to provide
fundamental ultrasound education in
the first and second years, with more
advanced ultrasound knowledge in the
third and fourth years, of residency
training. A competency assessment
process was developed for obtaining
specific ultrasound images that are part
of the basic obstetric and gynecologic
ultrasound examinations. In addition,
writing an ultrasound report, assessing
ultrasound components of the biophys-
ical profile, and performing third-
trimester amniocentesis were included.
By expert consensus, the curriculum was
developed for each year of training,
criteria for each competency assess-
ment image were generated, the pass
score was established at or close to,
75% for each, and obtaining a set of 5
ultrasound images with pass score in
each was deemed necessary for attain-
ing each competency. Some compe-
tencies, such as measurement of the
uterus, require >1 image to be ob-
tained and the pass score was estab-
lished taking into account the criteria
of all required images. The consensus
decision to establish competency on
the basis of 5 image submissions was
supported by data (albeit limited) in
the literature. In a study assessing
performance measures and learning
curves for use of an ultrasound simu-
lator, novices reached the level of an
expert with a median of 5 iterations.7
In another prospective cohort study
on the usability of simulation training
in obstetric ultrasonography, measure-
ments of crown-rump length, head
circumference, and femur diaphysis
length were attained consistently with
5 iterations.8
Given the current lack of substantial
data on competency assessment in ul-
trasound training, the task force expects
that the criteria set forth in this docu-
ment will evolve with time. The task
force encourages use of ultrasound
simulation in residency training and
expects that simulation will be a signifi-
cant part of the curriculum and the
ajog.org
competency assessment process. In a
recent study, the validity of an obstetric
ultrasound simulator as a tool for eval-
uating trainees following structured
training was compared to using stan-
dardized ultrasound planes obtained
from volunteers.9 Images obtained from
the simulator and from the volunteer
subjects were scored according to previ-
ously established quality criteria. Scores
obtained from the obstetric ultrasound
simulator were significantly higher than
those obtained by volunteers. The study
showed that an obstetric ultrasound
simulator is as effective as volunteer-
based examination for evaluating prac-
tical skills of trainees follow-
ing structured training in obstetric
ultrasound.9
It is important to note that the com-
petency assessment aspect of this docu-
ment requires the trainee to obtain
personally the respective images for re-
view and evaluation. For specialties and
practices such as radiology practices, in
which the primary mode of ultrasound
training is based on interpretation of
images acquired by sonographers, the
competencies can be adapted to reflect
this.
Curriculum
Objectives of the curriculum are
organized around essential topics,
including basic principles of medical
ultrasound and characteristics of the
equipment, aspects of the ultrasound
examination, and ultrasound exami-
nation performance throughout the
stages of pregnancy and in gynecology.
The objectives are presented within a
level-based framework that will
allow trainees to progress along a
continuum toward increasing
competence.
Level 1 (year 1)
Basic principles of medical ultrasound

Basic principles of ultrasound
physics.

Ultrasound modes (B-mode, M-
mode, Doppler, 2-dimensional [2D]
and 3-dimensional [3D]).

Bioeffects of ultrasound (mechanical
and thermal effects: as low as
ajog.org
reasonably achievable [ALARA]
principle).10

Ultrasound artifacts.

Official statements from professional
societies (AIUM, ACOG, ACOOG,
ACR, ISUOG, SMFM, and SRU).
Basic characteristics of ultrasound
equipment (knobology)

Ultrasound transducers: principles of
sound generation; compare trans-
ducer characteristics and
applications.

Sound penetration and bioeffect with
consideration related to acoustic
power output.

Effect of frequency on resolution and
penetration.

Effect of depth settings on field of
view and image size.

Gain settings for optimal image bright-
ness with minimum power output.

Focal zone depths to achieve best
resolution of structures of interest.

Image persistence settings to reduce
background noise.

Inputting patient information into
ultrasound system before starting an
ultrasound examination.
Aspects of the ultrasound examination

Effective positioning of patients and
application of coupling agents.

Ergonomic practices that minimize
repetitive stress injuries (positioning
of operator and equipment).

Correct transducer manipulation and
image orientation.

Ultrasound image labeling and
storage.

Appropriate communication of ul-
trasound findings to other health
professionals.

Protocol for transducer cleaning and
disinfection.
Ultrasound in the first trimester

Steps for performance of first-
trimester transvaginal ultrasound
examination.

Indications for first-trimester ultra-
sound examination.

Gestational sac evaluation (intrauter-
ine location, discriminatory human
chorionic gonadotropin levels, and
differentiation from endometrial
fluid).

Yolk sac.

Amnion.

Embryo/fetus (number).

Embryo/fetus cardiac activity; docu-
ment with M-mode or movie clip.

Criteria for definitive diagnosis of
embryonic/fetal death in first
trimester.

Components of sonographic dating in
first trimester.

Ultrasound evaluation of ampullary
tubal ectopic pregnancy.

Subchorionic hematoma.

Sonographic features of molar
pregnancy.

Association between thickened nuchal
translucency and fetal chromosomal
anomalies.
Ultrasound in the second and third
trimesters

Components of basic second- and third-
trimester ultrasound examinations.

Components of fetal biometry in
sonographic dating in second and
third trimesters.

Predisposing factors for fetal macro-
somia and fetal growth restriction in
third trimester.

Imaging parameters for placental
localization.

Risks and indications for genetic
amniocentesis.
Ultrasound evaluation of twin
gestations

Role of ultrasound in diagnosis of
twins.

Chorionicity and amnionicity in
multifetal pregnancies.
Placental abnormalities

Risk factors and sonographic diag-
nosis of placenta previa and low-lying
placenta.

Risk factors of placenta accreta.
Amniotic fluid assessment
JANUARY 2018 American Journal of Obstetrics & Gynecology
Special Report

Methods for diagnosing
oligohydramnios.

Methods for diagnosing
polyhydramnios.
Ultrasound examination of nonpreg-
nant uterus

Indications for pelvic sonography.

Sonographic features of the normal
uterus in relation to the menstrual cycle.
Ultrasound evaluation of adnexa

Sonographic features of normal
ovary in relation to menstrual
cycle.

Characteristics of a simple cyst.
Level 2 (year 2)
Ultrasound in the first trimester

Sonographic appearance of major
fetal malformations in early gestation.

Atypical locations of ectopic preg-
nancy, including interstitial, ovarian,
cervical, abdominal, and cesarean scar
implantations.

Workup of pregnancy of unknown
location.
Ultrasound evaluation of twin
gestations

Methods of determining twin
placentation by ultrasound.

Role of ultrasound in follow-up of
twin gestations.

Role of ultrasound in serial evaluation
of discordant twins.

Sonographic findings of mono-
chorionic monoamniotic twins.
Placental abnormalities

Risk factors and sonographic diag-
nosis of vasa previa.

Risk factors and sonographic find-
ings of placenta accreta.

Role of ultrasound assessment of
placental abruption.
Amniotic fluid assessment

Ultrasound estimation of
amniotic fluid volume in twin
gestations.
31
Special Report
Cervix

Ultrasound measurement of cervical
length in second and third trimesters
of pregnancy.
Abnormalities of the nonpregnant
uterus

Ultrasound evaluation of anatomic
locations of leiomyomas.

Ultrasound evaluation of endometrial
abnormalities.
Ultrasound evaluation of adnexa

Sonographic characteristics of hem-
orrhagic cysts and their evolution
(gray-scale and color Doppler).

Sonographic characteristics of endome-
triomas (gray-scale and color Doppler).

Sonographic characteristics of mature
teratomas (gray-scale and color
Doppler).

Sonographic characteristics
pedunculated leiomyomas and
ovarian fibromas.

Sonographic characteristics
hydrosalpinx.

Sonographic characteristics
tubo-ovarian inflammatory
process (tubo-ovarian complex/
abscess).

Sonographic characteristics of peri-
toneal inclusion fluid.

Sonographic characteristics of poly-
cystic ovaries.

Sonographic characteristics
adnexal torsion.

Sonographic characteristics of malig-
nant adnexal masses.
Level 3 (year 3)
Ultrasound in the second and third
trimesters

Normal fetal head anatomy and
common malformations.

Normal fetal facial anatomy and
common malformations.

Normal fetal thoracic anatomy and
common malformations.

Normal fetal heart anatomy and
common malformations.

Normal fetal abdominal anatomy and
common malformations.
32 American Journal of Obstetrics & Gynecology JANUARY 2018

Normal fetal pelvic anatomy and
common malformations.

Normal fetal skeletal anatomy and
common malformations.

Role of umbilical artery Doppler
studies in evaluation of fetal growth
restriction.

Ultrasound diagnosis of
hydrops.

Writing the ultrasound report.
Ultrasound evaluation
gestations

Role of ultrasound in diagnosis and
management of twin-twin trans-
fusion syndrome.

Role of ultrasound in evaluation
of twin anemia-polycythemia
sequence and selective intrauterine
growth restriction in monochorionic
twins.

Role of umbilical artery Doppler
studies in the evaluation of fetal twin-
twin transfusion syndrome.
of
Ultrasound examination
nonpregnant uterus
of

Sonographic features of adenomyosis.
of

Classification of congenital uterine
malformations (2D and 3Dy
ultrasound).

Role of ultrasound in localization of
intrauterine contraceptive devices
(2D and 3Dy ultrasound).
Evaluation of the adnexa
of

Role of color Doppler in evaluation of
adnexal masses.

Prediction models for ovarian
cancer.

International Ovarian Tumor Anal-
ysis simple rules for classification of
adnexal masses.11

Sonographic features of
endometriosis.
Level 4 (year 4)
Ultrasound in the second and third
trimesters
yNote that this does not imply that the trainee needs to
attain competency in 3D ultrasound, but rather explain
the classification of uterine malformations and identify
location of intrauterine contraceptive devices based
upon 2D and 3D ultrasound.
ajog.org

Role of middle cerebral artery peak
systolic velocity in screening for fetal
anemia.
Ultrasound evaluation of twin
gestations

Sonographic features of conjoined
twins.

Role of ultrasound in diagnosis and
evaluation of twin reversed arterial
of twin perfusion.
Competency assessment
Competency is assessed by evaluation
of still ultrasound images, movie clips,
real-time scanning, or a combination
of methods, as determined by indi-
vidual programs. The pass score for
competency assessment was established
at, or close to, 75%, and a set of 5
ultrasound images with pass score in
each was deemed necessary for attain-
ing each competency. Missing the
specified criteria* fails the competency
for a particular image (or movie clip
of the
when appropriate). The competencies
are listed in Table 1. Details of each
competency assessment and corre-
sponding images are provided in
Appendix.
Conclusion
This document, endorsed by the AIUM,
SMFM, ACOOG, ISUOG, and Society of
Diagnostic Medical Sonography; recog-
nized by ACR and SRU; and supported
by ACOG and the Council on Resident
Education in Obstetrics and Gynecology
(CREOG), presents a consensus-based
curriculum and competency assessment
tools for performance of the basic ob-
stetric and gynecologic ultrasound ex-
amination, and is intended to represent
the minimum requirement for such
training. Programs may choose to sup-
plement this curriculum with additional
material on normal and abnormal con-
ditions as they see fit. It is understood
that individual training programs may
have different trajectories of curriculum
and competency assessment as they fit
*Indicates criteria that are essential to passing a compe-
tency. Missing the asterisked criteria will fail the respec-
tive competency.
ajog.org
into other components of the training
and clinical practice requirements. Ulti-
mately, the composite curriculum and
competency assessment should be ach-
ieved by the time of completion of resi-
dency training.
This curriculum is also applicable to
anyone who wants to learn how to
perform obstetric and gynecologic ul-
trasound examinations, even if they
have already completed their formal
training.
In parallel to this task force, the AIUM
has established another collaborative
task force to develop narrated pre-
sentations by expert sonologists on ul-
trasound topics in obstetrics and
gynecology, covering all aspects of the
curriculum of this task force.
We recognize that residency program
directors have the difficult task of
balancing training requirements with
limited flexibility in residency schedules.
Ideally, a structured rotation in ultrasound
during residency will facilitate ultrasound
training and help in development of the
technical skills required for the basic ob-
stetric and gynecologic ultrasound exam-
ination. A 2003 survey on obstetric
sonography by CREOG noted that 41% of
residency programs had a required ultra-
sound rotation and 64% had didactic ul-
trasound training.12 Although a
structured ultrasound rotation is ideal,
task force members believe that ultra-
sound training can also be performed
during other residency rotations, given
that ultrasound is embedded in obstetric
and gynecologic clinical care. We hope
that the curriculum and competency
assessment tools provided here will sup-
port residency program directors and will
serve to facilitate ultrasound training in
residency programs. The aforementioned
accompanying narrated lecture series will
be made available to program directors
among others, and the competency
assessment tools will serve to standardize
training and track progress during the
residency program.
We anticipate that simulation will
evolve to provide educational and
competency assessment products to
facilitate and accelerate residency
training in ultrasound. Ultrasound
simulators allow for flexibility in
Special Report
TABLE 1
List of competencies assessed during levels 1e4 (years 1e4)
1. Competency assessment: level 1 (year 1) (see Appendix Tables 1A to 1K)
A. Mean sac diameter
B. Crown-rump length
C. Fetal presentation
D. Fetal extremities
E. Biparietal diameter
F. Head circumference
G. Abdominal circumference
H. Femur diaphysis length
I. Biophysical profile (ultrasound components)
J. Amniotic fluid index
K. Maximum vertical pocket
2. Competency assessment: level 2 (year 2) (see Appendix Tables 2A to 2G )
A. Cervical length (transvaginal ultrasound)
B. Cervical length (transabdominal ultrasound)
C. Endometrial thickness
D. Uterine measurements
E. Ovarian measurements
F. Transvaginal pelvic examination: uterus
G. Transvaginal pelvic examination: ovaries
3. Competency assessment: level 3 (year 3) (see Appendix Tables 3A to 3P)
A. Head: transventricular plane
B. Head: transthalamic plane
C. Head: transcerebellar plane
D. Face: upper lip and philtrum
E. Four-chamber view
F. Left ventricular outflow tract
G. Right ventricular outflow tract
H. Abdomen: abdominal circumference level
I. Abdomen: kidneys
J. Abdomen: cord insertion
K. Number of cord vessels
L. Pelvis: bladder
M. Spine: longitudinal
N. Spine: axial
O. Writing a report: obstetrics
P. Writing a report: gynecology
4. Competency assessment: level 4 (year 4) (see Appendix Tables 4A and 4B)
A. Face: facial profile
B. Amniocentesis to assess fetal lung maturity
5. Additional competencies (not currently part of basic obstetric and gynecologic ultrasound
examination) (see Appendix Tables 5A to 5E)
A. Three vessels and trachea view
B. Face: orbits
C. Umbilical artery Doppler
D. Nuchal translucency
E. Saline contrast sonohysterography
Abuhamad et al. Obstetric and gynecologic ultrasound training. Am J Obstet Gynecol 2018.
competency assessment, as the simu- The task force believes that the cost of
lation can be performed remotely and ultrasound simulation will drop sub-
does not require patient interaction. stantially over time.
Standardized reports can be submitted Incorporating this training curricu-
electronically to program directors and lum and these competency assessment
the progress of ultrasound training and tools should promote consistency in
competency assessment can be tracked training and competency assessment,
over time. Local institutions should and thus enhance the performance
evaluate the cost-effectiveness of ultra- and diagnostic accuracy of ultrasound
sound simulation, and how it would fit examination in obstetrics and
into their respective residency training. gynecology. -
JANUARY 2018 American Journal of Obstetrics & Gynecology 33
Special Report
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ajog.org Special Report

APPENDIX TABLE 1A
Mean sac diameter
Pass grade:  7/9
Two images are required for this competency
Image 1:

Image magnified appropriately

Focal zone at appropriate level

Ultrasound plane at widest dimensions of gestational sac

Gestational sac measured in 2 orthogonal dimensions using inner-to-inner technique
Image 2:

Image magnified

Focal zone at appropriate level

Ultrasound plane of gestational sac perpendicular to that of image 1

Gestational sac measured at widest dimension using inner-to-inner technique

*Mean sac diameter appropriately calculated from mean of all 3 dimensions from images 1 and 2

APPENDIX FIGURE 1
Mean sac diameter

A, Gestational sac visualized in sagittal plane of uterus. Note length and height of gestational sac (measurements 1 and 2, respectively).
B, Maximum width of gestational sac measured in plane perpendicular to that of A. Mean sac diameter is calculated from mean of length, height
(A), and width (B). See Appendix Table 1A for corresponding competency list.

* Missing this criteria fails this competency.

Abuhamad et al. Obstetric and gynecologic ultrasound training. Am J Obstet Gynecol 2018.

JANUARY 2018 American Journal of Obstetrics & Gynecology 35

Special Report ajog.org

APPENDIX TABLE 1B
Crown-rump length
Pass grade: 4/5

Focal zone at appropriate level

Image magnified appropriately

Embryo/fetus imaged in neutral position

Maximum length of embryo/fetus shown

Maximum length of embryo/fetus measured in straight line from cranial to caudal

APPENDIX FIGURE 2
Crown-rump length (CRL)

Midsagittal plane in fetus at 12 weeks and 5 days, showing CRL measurement. See Appendix Table 1B for corresponding competency list.

Abuhamad et al. Obstetric and gynecologic ultrasound training. Am J Obstet Gynecol 2018.

APPENDIX TABLE 1C
Fetal presentation
Pass grade: 2/3

Focal zone at appropriate level

Longitudinal view of lower uterine segment above level of maternal pubic bone

*Fetal presenting body part identified in relation to cervical area

APPENDIX FIGURE 3
Fetal presentation

Midsagittal plane of uterus in lower uterine segment, showing A, cephalic (fetal head) and B, breech (fetal buttocks) presentations. Note midsagittal
view of cervix. See Appendix Table 1C for corresponding competency list.

* Missing this criteria fails this competency.

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APPENDIX TABLE 1D
Fetal extremities
Pass grade: 5/7
4 Images are required for this competencya

Focal zone at appropriate level

Image magnified appropriately

Longitudinal view of extremity shown
Image 1:

Right upper extremity, showing hand if possible
Image 2:

Left upper extremity, showing hand if possible
Image 3:

Right lower extremity, showing foot if possible
Image 4:

Left lower extremity, showing foot if possible

APPENDIX FIGURE 4
Ultrasound images of fetal upper and lower extremities

A, Upper extremities. Note appearance of humerus, ulna, and radius. Small portion of radius is shown, due to orientation of upper extremity. B,
Lower extremities. See Appendix Table 1D for corresponding competency list.

a
<4 Images are acceptable if both extremities are displayed clearly.
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APPENDIX TABLE 1E
Biparietal diameter
Pass grade: 10/13

Focal zone at appropriate level

Image magnified appropriately

*Axial plane of head

Symmetric appearance of cerebral hemispheres

Midline falx imaged

Thalami imaged

Cavum septi pellucidi imaged

Insula imaged

No cerebellum seen

Near caliper on outside edge of bone

Far caliper on inside edge of bonea

Measurement at widest diameter

Measurement perpendicular to falx
Passing this competency will also qualify for competency transthalamic plane in Table 3B

APPENDIX FIGURE 5
Biparietal diameter (BPD) - Transthalamic plane

A, Axial plane of fetal head at level of BPD, demonstrating falx cerebri, cavum septi pellucidi (CSP), thalami (T), third ventricle (V), and insula. Note,
BPD measurement in this image is from outside border of proximal parietal bone to inside border of distal parietal bone. B, Same image as in A.
BPD measurement in this image is from outside border of proximal parietal bone to outside border of distal parietal bone. See Appendix Table 1E
for corresponding competency list.

* Missing this criteria fails this competency; a Caliper may be placed on outer edge of bone based on existing practice patterns.
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APPENDIX TABLE 1F
Head circumference
Pass grade: 7/10

Focal zone at appropriate level

Image magnified appropriately

*Axial plane of head

Symmetric appearance of cerebral hemispheres

Midline falx imaged

Thalami imaged

Cavum septi pellucidi imaged

Insula imaged

No cerebellum seen

Measurement circumference ellipse on outside edge of bone
Passing this competency will also qualify for competency transthalamic plane in Table 3B

APPENDIX FIGURE 6
Head circumference (HC)

Axial plane of fetal head at biparietal diameter level (transthalamic), demonstrating falx cerebri, cavum septi pellucidi (CSP), thalami (T), third
ventricle (V), and insula. Measurement of HC is obtained using ellipse placed on outer edge of cranium. In this case, HC measures 21.74 cm,
corresponding to gestational age of 23 weeks and 6 days. See Appendix Table 1F for corresponding competency list.

* Missing this criteria fails this competency.

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APPENDIX TABLE 1G
Abdominal circumference
Pass grade: 8/11

Focal zone at appropriate level

Image magnified appropriately

*Axial plane of abdomen

Abdomen as circular as possible

Spine imaged in cross-section in 3- or 9-o’clock position if possible

Stomach bubble imaged

Intrahepatic portion of umbilical vein imaged in short segment

No more than one rib visible on each side laterally

Kidneys not visualized

Surrounding skin seen in entirety if possible

Measurement of circumference ellipse on outside edge of skin
Passing this competency will also qualify for competency abdominal circumference level in Table 3H

APPENDIX FIGURE 7
Abdominal circumference (AC)

Axial plane of fetal abdomen at level of AC. Note presence of intraabdominal portion of umbilical vein (UV), stomach (St), spine (Sp), descending
abdominal aorta (Ao), and inferior vena cava (IVC). Also note presence of large segments of individual ribs on each side laterally. See Appendix
Table 1G for corresponding competency list.

* Missing this criteria fails this competency.

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APPENDIX TABLE 1H
Femur diaphysis length
Pass grade: 5/7

Focal zone at appropriate level

Image magnified appropriately

*Whole femur diaphysis imaged

Ultrasound beam perpendicular to long axis of femur

Calipers placed at each end of ossified diaphysis

Longest visible diaphysis is measured

Spur artifacts on end of diaphysis not included in measurement

APPENDIX FIGURE 8
Femur diaphysis length (FL)

Longitudinal plane of femur, showing FL measurement. Note proximal and distal femoral epiphyses are not yet ossified and not included in FL
measurement. Also note presence of distal femoral spur, which should not be included in FL measurement. See Appendix Table 1H for
corresponding competency list.

* Missing this criteria fails this competency.

Abuhamad et al. Obstetric and gynecologic ultrasound training. Am J Obstet Gynecol 2018.

APPENDIX TABLE 1I
Biophysical profile (ultrasound components)
Pass grade: 6/6

*Length of examination: 30 min maximum, or until all criteria are met

*Breathing, movement and tone documented by movie clips if available

*30-s period of fetal breathing imaged

*Three gross fetal body or limb movements imaged

*Episode of flexion and extension of fetal limb(s) imaged

*Amniotic fluid volume evaluated by amniotic fluid index, maximal vertical pocket, or qualitative assessment
* Missing this criteria fails this competency.
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APPENDIX TABLE 1J
Amniotic fluid index
Pass grade: 6/8

Focal zone at appropriate level

Image at appropriate depth

Sagittal orientation of ultrasound transducer

4 Images labeled, 1 for each quadrant

Calipers placed on each image from top to bottom of maximal vertical pocket

Fluid space measured is devoid of any cord or body part

Measurement is vertical with respect to transducer placement

4 Quadrant measurements are added for amniotic fluid index calculation

APPENDIX FIGURE 9
Amniotic fluid index (AFI)

Four images (Q1-Q4), obtained from each of 4 quadrants of uterus. Maximum vertical pocket (MVP) is measured in each quadrant (Q1-Q4). AFI is
calculated by adding MVP from all 4 quadrants. In this fetus, AFI is normal (13.7 cm). MVP is measured in amniotic fluid from top to bottom in a
vertical line. See Appendix Table 1J for corresponding competency list.

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APPENDIX TABLE 1K
Maximal vertical pocket
Pass grade 4/6

Focal zone at appropriate level

Image at appropriate depth

Image displays maximal vertical pocket of amniotic fluid

Calipers placed from top to bottom of maximal vertical pocket

Fluid space measured is devoid of any cord or body parts

Measurement is vertical with respect to transducer placement

APPENDIX FIGURE 10
Maximal vertical pocket (MVP)

Ultrasound image of MVP for determination of amniotic fluid volume. MVP is determined by scanning all 4 quadrants of uterus and measuring MVP
in quadrant with largest amount of amniotic fluid. MVP is measured in amniotic fluid from top to bottom in vertical line. See Appendix Table 1K for
corresponding competency list.

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APPENDIX TABLE 2A
Cervical length (transvaginal ultrasound)
Pass grade: 7/10

Transvaginal ultrasound

Midsagittal plane of cervix

Focal zone at appropriate level

Image magnified appropriately

Anterior cervical width is equal to posterior cervical width

Maternal bladder empty

Internal os seen

External os seen

Cervical canal visible throughout

Caliper placement correct

APPENDIX FIGURE 11
Transvaginal cervical length measurement

Midsagittal plane of cervix obtained by transvaginal approach. Note cervical length is measured from internal to external cervical os (3.8 cm in this
example). Note anterior position of maternal bladder and presenting fetal head. See Appendix Table 2A for corresponding competency list.

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APPENDIX TABLE 2B
Cervical length (transabdominal ultrasound)
Pass grade: 6/8

Transabdominal ultrasound

Focal zone at appropriate level

Image magnified appropriately

Midsagittal plane of cervix

Maternal bladder nondistended

Internal os seen

External os seen

Caliper placement correct

APPENDIX FIGURE 12
Transabdominal cervical length measurement

Midsagittal plane of cervix obtained by transabdominal approach. Note cervical length is measured from internal to external cervical os (4 cm in this
example). Fetal head is presenting. Note location of vaginal canal. Distention of maternal bladder may impact measurement of cervical mea-
surement on transabdominal approach. See Appendix Table 2B for corresponding competency list.

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APPENDIX TABLE 2C
Endometrial thickness
Pass grade: 5/7

*Transvaginal ultrasound

Focal zone at appropriate level

Midsagittal plane of cervix and uterus, with magnification of endometrium as needed for endometrial measurement

Endometrial lining (echo) seen in its entirety from cervical canal to endometrial fundus

Cul-de-sac imaged posterior to cervix

Calipers placed in anteroposterior orientation, perpendicular to long axis of uterus, using outer-to-outer techniquea

Widest endometrial thickness measured using outer-to-outer technique

APPENDIX FIGURE 13
Endometrial thickness

Midsagittal plane of uterus obtained for measurements of endometrial thickness. Note midline endometrial lining (echo) is seen in its entirety from
cervical canal to endometrial fundus. Measurement of endometrial thickness is obtained by placing calipers in anteroposterior orientation,
perpendicular to long axis of uterus and using outer-to-outer technique. See Appendix Table 2C for corresponding competency list.

* Missing this criteria fails this competency; a In presence of endometrial fluid, measure anterior and posterior endometrial walls separately and add 2 measurements.
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APPENDIX TABLE 2D
Uterine measurements
Pass grade: 7/10
Two images are required for this competency

Transvaginal ultrasound

Focal zone at appropriate level

Image magnified appropriately
Image 1:

Midsagittal plane of cervix and uterus

Endometrial lining seen in its entirety from cervical canal to endometrial fundus

Cul-de-sac imaged posterior to cervix

Length of uterus measured from fundus to external os using outer-to-outer techniquea; alternate method for measurement of uterine length
includes measurement from fundal region, along endometrial lining and endocervical canal, using outer-to-outer technique

Anteroposterior diameter of uterus measured from anterior to posterior serosal surface at widest dimension perpendicular to long axis of uterus
using outer-to-outer technique
Image 2:

Transverse (axial) plane of uterus at widest dimension

Transverse diameter of uterus measured from left to right serosal surface at widest dimension using outer-to-outer technique
Passing this competency will also qualify for competency transvaginal pelvic examination: uterus in Table 2F.

APPENDIX FIGURE 14
Uterine measurements: midsagittal plane

A1 and A2, Midsagittal plane of uterus obtained for measurements of uterine length and height. Note endometrial lining (echo) is seen in its entirety
from cervical canal to endometrial fundus. Length of uterus (measurement 1) is measured from fundus to outer edge of cervix. In this midsagittal
plane, anteroposterior diameter of uterus is also measured at widest dimension (measurement 2), perpendicular to long axis of uterus. A2, Length
of uterus is measured following endometrial lining and endocervical canal, using outer-to-outer technique. This technique of uterine measurement
allows for more accuracy in presence of uterine flexion. B, Uterine measurements: transverse plane. Transverse plane of uterus, shown at its
widest dimension. Uterine width is measured from left to right at widest uterine dimension. See Appendix Table 2D for corresponding
competency list.

a
Morphological uterus sonographic assessment is another method that can be followed/used for uterine measurement.13
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APPENDIX TABLE 2E
Ovarian measurements
Pass grade: 6/8
Two images are required for this competency
Perform for left and for right ovary

Transvaginal ultrasound

Focal zone at appropriate level

Image magnified appropriately
Image 1:

Plane of pelvis showing ovary with clear outline in longest dimension

Length of ovary measured from anterior to posterior at longest dimension

Anteroposterior diameter of ovary measured from left to right, orthogonal to length measurement
Image 2:

Plane of pelvis showing ovary with clear outline at right angles to image 1

Width of ovary measured from left to right at widest dimension
Passing this competency will also qualify for competency transvaginal pelvic examination: ovaries in Table 2G

APPENDIX FIGURE 15
Ovarian measurements: longitudinal and axial planes

A, Longitudinal plane of ovary, showing measurements of ovarian length and anteroposterior diameter. Anteroposterior diameter is measured
perpendicular to length measurement. B, Axial plane of ovary, perpendicular to longitudinal plane (A), showing ovarian width measurement.
See Appendix Table 2E for corresponding competency list.

Abuhamad et al. Obstetric and gynecologic ultrasound training. Am J Obstet Gynecol 2018.

APPENDIX TABLE 2F
Transvaginal pelvic examination: uterus
Pass grade: 5/7
Two images are required for this competency

Transvaginal ultrasound

Focal zone at appropriate level

Image magnified appropriately
Image 1: Longitudinal view

Midsagittal plane of cervix and uterus

Endometrial lining seen in its entirety from cervical canal to endometrial fundus

Cul-de-sac imaged posterior to cervix
Image 2: Axial view

Axial plane of uterus at widest dimension
Competency for this plane can also be established as part of uterine measurement competency in Table 2D
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APPENDIX TABLE 2G
Transvaginal pelvic examination: ovaries
Pass grade: 3/4
Two images are required for this competency
Perform for left and for right ovary

Focal zone at appropriate level

Image magnified appropriately
Image 1:

Parasagittal plane of pelvis showing ovary with clear outline in longest dimension
Image 2:

Axial plane of pelvis showing ovary with clear outline at right angles to image 1
Competency for this plane can also be established as part of ovarian measurement competency in Table 2E
Abuhamad et al. Obstetric and gynecologic ultrasound training. Am J Obstet Gynecol 2018.

APPENDIX TABLE 3A
Head: transventricular plane
Pass grade: 6/8

Focal zone at appropriate level

Image magnified appropriately

*Axial plane of head

Symmetric appearance of cerebral hemispheres

Midline falx imaged

Atrium and occipital horn of lateral ventricle clearly imaged

Measurement of atrium of lateral ventricle at level of parietooccipital groove

Calipers placed on medial and lateral walls of atrium of lateral ventricle perpendicular to long axis of ventricle using inner-to-inner technique

APPENDIX FIGURE 16
Transventricular plane

Axial view of fetal head at level of transventricular plane. Note that the choroid plexus does not extend into the occipital horns. Measurement of
lateral ventricle is obtained at atrium, at level of parietooccipital groove. Calipers are placed on medial and lateral walls, perpendicular to long axis
of ventricle, using inner-to-inner technique. Although cavum septi pellucidi (CSP) is seen in this figure, it does not have to be visualized as, on many
occasions, lateral ventricle can be seen in plane that is superior to CSP. See Appendix Table 3A for corresponding competency list.

* Missing this criteria fails this competency.

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APPENDIX TABLE 3B
Head: transthalamic plane
Pass grade: 7/9

Focal zone at appropriate level

Image magnified appropriately

*Axial plane of head

Symmetric appearance of cerebral hemispheres

Midline falx imaged

Thalami imaged

Cavum septi pellucidi imaged

Insula imaged

No cerebellum seen
Competency for this plane can also be established as part of biparietal diameter measurement competency, as shown in Table 1E
* Missing this criteria fails this competency.
Abuhamad et al. Obstetric and gynecologic ultrasound training. Am J Obstet Gynecol 2018.

APPENDIX TABLE 3C
Head: transcerebellar plane
Pass grade: 7/9

Focal zone at appropriate level

Image magnified appropriately

*Angled axial plane of head

Symmetric appearance of cerebellar hemispheres

Midline falx imaged

Thalami imaged

Cavum septi pellucidi imaged

*Cerebellar vermis imaged

*Cisterna magna imaged

APPENDIX FIGURE 17
Transcerebellar plane

Angled axial plane of fetal head, showing posterior fossa. Note symmetric appearance of cerebellar hemisphere, cerebellar vermis, and
cisterna magna. In this plane, falx cerebri, cavum septi pellucidi (CSP), and thalami (T) are also seen. See Appendix Table 3C for corresponding
competency list.

* Missing this criteria fails this competency.

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APPENDIX TABLE 3D
Face: upper lip and philtrum
Pass grade: 3/4

Focal zone at appropriate level

Image magnified appropriately

Coronal view of upper lip and philtrum

*Soft tissue of upper lip, philtrum, and nares clearly imaged

APPENDIX FIGURE 18
Upper lip and philtrum

Coronal view of fetal face, showing upper lip and philtrum. Note appearance of soft tissue of upper lip, philtrum, and nares. See Appendix Table 3D
for corresponding competency list.

* Missing this criteria fails this competency.

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APPENDIX TABLE 3E
Four-chamber view
Pass grade: 5/7

Focal zone at appropriate level

Image magnified appropriately

*Transverse (axial) plane of fetal chest

No more than one rib seen on each side of chest laterally

Chest as circular as possible

Spine imaged in cross-section

*Four chambers imaged

APPENDIX FIGURE 19
Four-chamber view

Axial view of fetal chest at level of 4-chamber view of heart. Note appearance of 4 chambers with right ventricle (RV) as most anterior chamber, and
left atrium (LA) as most posterior chamber. Left ventricle (LV) and right atrium (RA) are also seen. Note location of descending thoracic aorta (Ao),
and spine (Sp) posteriorly. Note that apex of heart is towards fetal left side and note presence of large segments of individual ribs. See Appendix
Table 3E for corresponding competency list.

* Missing this criteria fails this competency.

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APPENDIX TABLE 3F
Left ventricular outflow tract
Pass grade: 4/5

Focal zone at appropriate level

Image magnified appropriately

Angled axial plane of fetal chest

*LVOT imaged with continuity of ascending aorta with ventricular septum

LVOT imaged with no division of ascending aorta (which excludes transposition)

APPENDIX FIGURE 20
Left ventricular (LV) outflow tract

Angled axial plane of fetal chest, showing LV outflow tract, aorta (Ao). Note Ao arising from LV, and continuity of Ao with ventricular septum. See
Appendix Table 3F for corresponding competency list.
LA, left atrium; RA, right atrium; RV, right ventricle.

LVOT, left ventricular outflow tract.

* Missing this criteria fails this competency.
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APPENDIX TABLE 3G
Right ventricular outflow tract
Pass grade: 3/4

Focal zone at appropriate level

Image magnified appropriately

Transverse or parasagittal plane of upper fetal chest

*RVOT imaged with pulmonary valve shown

APPENDIX FIGURE 21
Right ventricular (RV) outflow tract

Transverse plane of fetal upper chest at level of RV outflow tract. Note pulmonary artery (PA), superior to aorta (Ao). Also note pulmonary valve (PV).
See Appendix Table 3G for corresponding competency list.

RVOT, right ventricular outflow tract.

* Missing this criteria fails this competency.
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APPENDIX TABLE 3H
Abdomen: abdominal circumference level
Pass grade: 7/10

Focal zone at appropriate level

Image magnified appropriately

*Axial plane of abdomen

Abdomen as circular as possible

Spine imaged in cross-section in 3- or 9-o’clock position if possible

Stomach bubble imaged

Intrahepatic portion of umbilical vein imaged in short segment

No more than 1 rib visible on each side laterally

Kidneys not visualized

Surrounding skin seen in its entirety if possible
Competency for this plane can also be established as part of abdominal circumference measurement competency, as shown in Table 1G
* Missing this criteria fails this competency.
Abuhamad et al. Obstetric and gynecologic ultrasound training. Am J Obstet Gynecol 2018.

APPENDIX TABLE 3I
Abdomen: kidneys
Pass grade: 3/4

Focal zone at appropriate level

Image magnified appropriately

Coronal, parasagittal, or axial view of abdomen

*Right and left kidneys imaged in 1 or 2 images

APPENDIX FIGURE 22
Kidneys: axial, coronal, and sagittal planes

A, Axial plane of fetal abdomen at level of kidneys. Note right and left kidneys and renal pelves, imaged in posterior aspect of fetal abdomen, lateral
to fetal spine. B, Coronal plane of fetal posterior abdomen. Note presence of right and left kidneys in coronal view. C, Sagittal plane of right side of
abdomen, showing right kidney. See Appendix Table 3I for corresponding competency list.

* Missing this criteria fails this competency.

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APPENDIX TABLE 3J
Abdomen: cord insertion
Pass grade: 3/4

Focal zone at appropriate level

Image magnified appropriately

Axial or midsagittal plane of abdomen

*Umbilical cord imaged inserting into anterior abdominal wall, outlined by amniotic fluid, with abdominal wall visualized clearly on both sides of
cord insertion

APPENDIX FIGURE 23
Abdominal cord insertion

Axial plane of fetal abdomen at level of cord insertion. Note insertion of umbilical cord into anterior abdominal wall. See Appendix Table 3J for
corresponding competency list.

* Missing this criteria fails this competency.

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APPENDIX TABLE 3K
Number of cord vessels
Pass grade: 3/4

Focal zone at appropriate level

Image magnified appropriately

*Cross-sectional view of umbilical cord in amniotic fluid or axial view of fetal pelvis with color Doppler

*Presence of 2 fetal umbilical arteries around bladder

APPENDIX FIGURE 24
Number of cord vessels

A, Axial plane of fetal pelvis (color Doppler) at level of fetal bladder. Note presence of 2 umbilical arteries, lateral to bladder. B, Axial plane (gray-
scale) of free loop of umbilical cord in amniotic fluid, showing umbilical vein and 2 umbilical arteries. C, Axial plane (color Doppler) of free loop of
umbilical cord in amniotic fluid (B), showing umbilical vein and 2 umbilical arteries. Note that blood flow in umbilical vein is in reverse direction to
that of umbilical artery. See Appendix Table 3K for corresponding competency list.

* Missing this criteria fails this competency.

Abuhamad et al. Obstetric and gynecologic ultrasound training. Am J Obstet Gynecol 2018.

APPENDIX TABLE 3L
Pelvis: bladder
Pass grade: 3/4

Focal zone at appropriate level

Image magnified appropriately

Coronal, sagittal, or axial view of abdomen/pelvis

*Bladder imaged in anterior aspect of pelvis

APPENDIX FIGURE 25
Bladder

Axial plane of the fetal pelvis showing the bladder. See Appendix Table 3L for corresponding competency list.

* Missing this criteria fails this competency.

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APPENDIX TABLE 3M
Spine: longitudinal
Pass grade: 5/7
Three images/sweeps are required for this competency

Focal zone at appropriate level

Image magnified appropriately

*Midsagittal plane of spine

*Overlying skin imaged outlined by amniotic fluid
Image 1:

*Entire length of cervical spine evaluated
Image 2:

*Entire length of thoracic spine evaluated
Image 3:

*Entire length of lumbosacral spine evaluated

APPENDIX FIGURE 26
Longitudinal spine

A, Midsagittal plane of fetal spine at level of cervical and thoracic region. Note that entire length of cervical and thoracic spine is shown, with normal
overlying skin and no spinal abnormalities. Spinous process and corresponding vertebral body is seen for each vertebra. B, Midsagittal plane of
fetal spine at level of thoracic region. Note that entire length of thoracic spine is shown, with normal overlying skin and no spinal abnormalities.
Spinous process and corresponding vertebral body is seen for each vertebra. C, Midsagittal plane of fetal spine at level of lumbosacral region. Note
that entire length of lumbosacral spine is shown, with normal overlying skin and no spinal abnormalities. Spinous process and corresponding
vertebral body is seen for each vertebra. See Appendix Table 3M for corresponding competency list.

* Missing this criteria fails this competency.

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APPENDIX TABLE 3N
Spine: axial
Pass grade: 5/7
Three images/sweeps are required for this competency

Focal zone at appropriate level

Image magnified appropriately

*Axial plane(s) of spine

Overlying skin imaged outlined by amniotic fluid
Image/sweep 1:

*Entire length of cervical spine evaluated
Image/sweep 2:

*Entire length of thoracic spine evaluated
Image/sweep 3:

*Entire length of lumbosacral spine evaluated

APPENDIX FIGURE 27
Axial spine

A, Axial plane of fetal spine at level of cervical spine. Note normal orientation of spinal lateral processes and normal overlying skin. B, Axial plane of
fetal spine at level of thoracic spine. Note normal orientation of spinal lateral processes and normal overlying skin. C, Axial plane of fetal spine at
level of lumbosacral spine. Note normal orientation of spinal lateral processes and normal overlying skin. Iliac bones are seen in pelvis laterally on
each side. See Appendix Table 3N for corresponding competency list.

* Missing this criteria fails this competency.

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APPENDIX TABLE 3O
Writing ultrasound report: obstetrics
Pass grade is assessed subjectively based on review of listed criteria
Ensure that essential criteria* are included as appropriate
Patient identification and pertinent characteristics:

*Patient name

*Identification numbers

*Examination date

Patient date of birth

Patient gravidity and parity if clinically relevant

Pregnancy dating as available

*Indication for ultrasound examination
Basic information:

*Presence or absence of cardiac activity

*Location of gestational sac

*Number of fetuses

*Location of fetuses in multiple pregnancy

*Placental location

*Type of placentation in multiple pregnancy

*Assessment of amniotic fluid

*Fetal lie and presentation
Fetal biometric measurements:

*Mean sac diameter (if no embryo/fetus)

*Crown-rump length

*Biparietal diameter

*Head circumference

*Abdominal circumference

*Femur diaphysis length
Fetal anatomy:

Described appropriate to setting and resources

*Basic anatomy

Detailed anatomy

*Estimated gestational age based on established guidelines

*Estimated fetal weight (>24 wk)

*Summary of examination and comments

Comparison with previous studies

Limitations of ultrasound examination

Recommendations for follow-up if necessary
* Essential criteria.
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APPENDIX TABLE 3P
Writing ultrasound report: gynecology
Pass grade is assessed subjectively based on review of listed criteria
Ensure that essential criteria (indicated by asterisk) are included as appropriate
Patient identification and pertinent characteristics:

*Patient name

*Identification numbers

*Date of examination

Patient date of birth

Patient gravidity and parity if clinically relevant

Mode of previous delivery(ies) if applicable

Date of last menstrual period

*Indication for ultrasound examination
Biometric information:

*Uterine height, length, and width

*Ovarian measurements in 3 dimensions are required part of imaging, but not of written report

*Cul-de-sac: fluid or abnormalities
Abnormalities:

*Uterine

*Adnexal

*Cul-de-sac

*Surrounding pelvic structures
Final diagnosis and follow-up:

*Summary of examination and comments

Comparison with previous studies

Limitations of ultrasound examination

Recommendations for follow-up if necessary
* Essential criteria.
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APPENDIX TABLE 4A
Face: facial profile
Pass grade: 5/7

Focal zone at appropriate level

Image magnified appropriately

*Midsagittal view of face

Tip of nose imaged

Nasal bone imaged

Mandible imaged

Maxilla imaged

APPENDIX FIGURE 28
Fetal facial profile

Midsagittal plane of fetal face, showing facial profile. Note tip of nose, nasal bone, maxilla, and mandible. See Appendix Table 4A for corresponding
competency list.

* Missing this criteria fails this competency.

Abuhamad et al. Obstetric and gynecologic ultrasound training. Am J Obstet Gynecol 2018.

APPENDIX TABLE 4B
Amniocentesis to assess fetal lung maturity
For obstetric and gynecologic residents only
Pass grade is assessed subjectively based on review of listed criteria
Indication for amniocentesis

Written and oral information provided

Informed consent signed

Maternal blood type reviewed
Procedure

Timeout before procedure

Fetal viability established before procedure

Needle insertion performed under ultrasound guidance

Transplacental puncture avoided if possible

Needle gauge 22e20

Maximum of 2 insertions

Volume of amniotic fluid retrieved as needed for test

Fetal well-being: assessment of fetal heart rate after procedure

RhO(D) immune globulin administered if indicated
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APPENDIX TABLE 5A
Three vessels and trachea view
Pass grade: 6/8

Focal zone at appropriate level

Image magnified appropriately

*Angled axial plane of fetal upper chest

Spine imaged in cross-section

Pulmonary artery/ductal arch imaged as anterior vessel

Ascending aorta/aortic isthmus imaged as middle vessel

Superior vena cava imaged in cross-section as posterior vessel

Ductal arch and aortic arch meet and both are shown to left of trachea

APPENDIX FIGURE 29
Three vessels and trachea view

A, Angled axial plane of the fetal upper chest, showing 3 vessels and trachea view. Note anterior location of pulmonary artery (PA), with ductus
arteriosus (DA) connecting with descending aorta (Ao). Ao and Ao isthmus are also seen connecting with descending Ao. Superior vena cava (SVC)
is seen in cross-section to right side of Ao. Note that DA and Ao isthmus are to left side of trachea, confirming presence of normal left Ao and DA.
Spine (Sp) is seen posteriorly. B, Three vessels and trachea view: color Doppler. Note that color Doppler shows blood flow in both DA and Ao
isthmus towards descending Ao. See Appendix Table 5A for corresponding competency list.

* Missing this criteria fails this competency.

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APPENDIX TABLE 5B
Face: orbits
Pass grade: 3/4

Focal zone at appropriate level

Image magnified appropriately

*Coronal or axial views of upper face, showing 2 orbits in same image

Bony edges of both orbits clearly imaged

APPENDIX FIGURE 30
Orbits

Axial view of upper face, showing 2 bony orbits. See Appendix Table 5B for corresponding competency list.

* Missing this criteria fails this competency.

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APPENDIX TABLE 5C
Umbilical artery Doppler
Pass grade: 7/9

A loop of umbilical cord imaged

Image magnified appropriately

Color Doppler applied if necessary

*Sample Doppler gate on umbilical artery

Wall filter sufficiently low to detect low-velocity flow

Scale and baseline set so waveforms occupy >50% of height of Doppler scale

Doppler velocimetry tracing demonstrates at least 5 consecutive similar waveforms

Doppler velocimetry tracing acquired in absence of fetal breathing and hiccups

Waveform(s) selected for measurements (pulsatility index, resistance index, or S/D ratio) are similar

APPENDIX FIGURE 31
Umbilical artery Doppler

Color and pulsed Doppler of umbilical artery obtained at level of placental cord insertion. Note that Doppler waveforms show forward flow during
diastole (D). Note also peak of waveforms, corresponding to peak systole (S). See Appendix Table 5C for corresponding competency list.

S/D ratio, Systolic / Diastolic ratio.

* Missing this criteria fails this competency.
Abuhamad et al. Obstetric and gynecologic ultrasound training. Am J Obstet Gynecol 2018.

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APPENDIX TABLE 5D
Nuchal translucency measurement
Pass grade: 7/9

Midsagittal plane of fetus

Image magnified with fetal head occupying majority of ultrasound image

Fetal head in neutral position

Fetus observed away from amnion

Margins of NT edges clear

Calipers (þ) used

Caliper horizontal cross bars are placed on NT line

Calipers placed perpendicular to long axis of fetus

Measurement is at widest NT space using on-to-on technique
NT measurement requires official certification before clinical practice

APPENDIX FIGURE 32
Nuchal translucency (NT)

Midsagittal plane of fetus in first trimester of pregnancy, showing measurement of NT. Note in this midsagittal plane, tip of nose, maxilla, and
midbrain are all visible. Also note that amnion is seen as separate membrane from NT. Measurement of NT is performed by placement of calipers at
widest NT space, using on-to-on technique. See Appendix Table 5D for corresponding competency list.

NT, nuchal translucency.

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APPENDIX TABLE 5E
Saline contrast sonohysterography
Pass grade: review components with trainee
Preparation for procedure:

Review indication for procedure

Ensure no contraindications for procedure exist

Obtain informed consent

Evaluate for presence of sexually transmitted diseases and need for antibiotic prophylaxis

Prepare required equipment

Ensure timing of procedure is in early proliferative phase and when patient is not actively bleeding
Procedure:

Timeout performed before procedure

Patient in supine position

Transvaginal ultrasound used
Image criteria:

Long-axis view of endometrial cavity during fluid injection

Adequate endometrial cavity distension (probe pressure at internal os in sagittal orientation to maintain distension)

3-Dimensional volume if available: sagittal, transverse, and coronal views

2-Dimensional views:

Sagittal view: to include entire endometrial cavity

Transverse view: fundus, miduterine, and lower-uterine segments

Real-time evaluation of endometrial cavity with targeted image capture

Endometrial wall thickness: anterior and posterior walls measured separately

Define/describe endometrium: global/uniform, focal irregularity (mass, polyp, or fibroid)

APPENDIX FIGURE 33
Saline contrast sonohysterography

A, Saline contrast sonohysterography. Midsagittal plane of uterus obtained during sonohysterography. Note distended endometrial cavity and
sonohysterography catheter in isthmic portion of uterus. Note that cavity is normal without any visible abnormality. B, Sonohysterography: 3-
dimensional (3D) volume. 3D Ultrasound volume of uterus obtained during sonohysterography. A, Transverse, B, sagittal, and C, coronal
planes. 3D Coronal plane is also displayed in lower right quadrant. Note that coronal planes in 2-dimensional and 3D images show normal
endometrial cavity without any abnormality. See Appendix Table 5E for corresponding competency list.

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