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2nd and 3rd Trimester OB Protocol

Protocol


Protocol will vary with patient age and fetal position
The goal of the exam is to image each structure in the protocol
The protocol is divided up into sections
 It is highly recommended that you complete each image in the applicable section before moving to
the next section when possible.
Placenta Comp Images- Heart Rate, Uterine Cervix, Ovaries, Adnexa, Placenta, and Fluid

Structure/
Order

Scan
Plane

Label

Landmarks Identified

Uterus/
Fetus

Uterine
Cervix

Adnexa

TX

NO IMAGE-SCAN
THROUGH

TX

HEART RATE

TX

HEART RATE

Sagittal

CERVIX ML

Sagittal

CERVIX ML







Sagittal

FETAL LIE


Sagittal
Sagittal

ADNEXA SAG RT
ADNEXA SAG LT
PLACENTA
SAG INF
PLACENTA
SAG MID
PLACENTA
SAG SUP
Q1









Q2

Q3

Sagittal
Placenta

Sagittal
Sagittal

Amniotic
Fluid Index
(volume)
Q1+Q2+Q3
+Q4= AFI
*Structures
seen in each
pocket will
vary

Sagittal
Sagittal
Sagittal


Sagittal

Q4

Begin at cervix, move superiorly out of uterine fundus
o Identify the fetus within the uterus
o Identify number of fetuses
o Identify fetal lie
o Determine the right and left sides of the fetus
Fetal heart and chest
o Enlarge image of heart and document heart rate
with M-mode or Spectral Doppler
Fetal heart and chest
o Enlarge image of heart and document heart rate
with a cine-loop
Vaginal Canal
Cervix
Amniotic Sac
Vaginal Canal
Cervix
Amniotic Sac
Measure Cervical Length
o External os to internal os
Document presenting fetal structure
Cervix
o Indicate Breech or Vertex in annotation
RT Adnexa include ovary if possible
LT Adnexa include ovary if possible
Placenta closest to Cervix
Retroplacental complex
Placenta Mid- include cord insertion
Retroplacental complex
Placenta- superior portion
Retroplacental complex
Measure largest vertical pocket clear of fetal components
from Anterior to Posterior
Measure largest vertical pocket clear of fetal components
from Anterior to Posterior
Measure largest vertical pocket clear of fetal components
from Anterior to Posterior
Measure largest vertical pocket clear of fetal components
from Anterior to Posterior

HMP:\Protocols\OBGYN Protocols\2nd Trimester Protocol.docx

2nd and 3rd Trimester OB Protocol
Fetal Measurements
Structure/
Order

Scan
Plane

Label

Fetal
Measurements

BPD



HC


Trans
Axial

CEREBELLUM


CISTERNA
MAGNA


NUCHAL FOLD

Abdomen
TX

Long
Bone

AC






FL



Long
Bone

HL

Landmarks Identified
Cavum septum pellucidum, IHF, Thalami and Parietal
bones
Measurement technique
Place calipers on the outside of the closet parietal
bone to the inside of the farthest parietal bone
Cavum septum pellucidum, IHF, Thalami and Parietal
bones
Measurement technique
o Place calipers outside to outside of the parietal
bones
o Open the calipers with an ellipse that surrounds
the fetal skull
IHF, Cerebral Peduncles, Cerebellum, Cisterna
Magna, and Nuchal Fold
Measurement technique
o Place calipers on the outside of the lateral wall to
the outside of the opposite lateral wall
IHF, Cerebral Peduncles, Cerebellum, Cisterna
Magna, and Nuchal Fold
Measurement technique
o Place calipers at the level of the mid posterior
wall of the cerebellum to the inside of occipital
bone
IHF, Cerebral Peduncles, Cerebellum, Cisterna
Magna, and Nuchal Fold
Measurement technique
o Place calipers at the level of the mid posterior
wall of the cerebellum from the outside of
occiptal bone to outside skin line
Umbilical vein/portal vein junction
3 points of the spine
Symmetrical ribs
Measurement technique
o Place calipers on outside of skin line directly
behind spine and in front of abdomen.
o Open calipers to form an ellipse around
abdomen including the skin line
Femur bone with distal or end shadowing
Measurement technique
o Place calipers from end to end on the femur Do not include epiphysis point
o Calipers should dissect the middle of the bone
Humerus bone with distal or end shadowing
Measurement technique
o Place calipers from end to end on the
humerus-Do not include epiphysis point
o Calipers should dissect the middle of the bone

HMP:\Protocols\OBGYN Protocols\2nd Trimester Protocol.docx

2nd and 3rd Trimester OB Protocol

Fetal Head and Face Structures
Organ/
Order

Scan Plane

Label

Landmarks Identified

Fetal Head
Coronal

CHP


IHF
Choroid Plexus within ventricle
o Try to get both in one image, if not do
separately (in axial plane)

Fetal Head
Transaxial

VENTRICLES
(indicate
RT & LT)


IHF
Ventricles



IHF
Ventricle
Measurement Technique
o Posterior ventricle
o Measure internally lateral to medial at glomus

FACE


Orbits
Mandible

LENS


Orbits
Echogenic lens (can be in transaxial plane)

NOSE AND LIPS


Nostrils
Upper lip

PROFILE

Forehead, nose, extended chin and neck

Fetal
Head

VENTRICLES
(indicate
RT & LT)

Fetal Face

Face
Coronal

Face
Midline
Sagittal

HMP:\Protocols\OBGYN Protocols\2nd Trimester Protocol.docx

2nd and 3rd Trimester OB Protocol

Organ/
Order

Fetal Thorax, Abdomen and Pelvic Structures
Scan Plane
Label
Landmarks Identified

Sagittal
Thorax/
Abdomen
Sagittal

Stomach

Transverse

Transverse

Kidneys

DIAPHRAGM
RT



RT lung
Diaphragm
Liver

DIAPHRAGM
LT



LT lung
Diaphragm
Stomach


Stomach
Transverse spine



Transverse spine
Right kidney
Left kidney
Left Sagittal Kidney (can be taken in coronal)
Measurement technique
o Superior to inferior border
Left Sagittal Kidney (can be taken in coronal)
Measurement technique
o Superior to inferior border
Transverse spine
Umbilical cord insertion into abdomen
Abdominal skin line
Umbilical cord projecting from abdomen

STOMACH

KIDNEYS

Sagittal

RK SAG


Sagittal

LK SAG


Transverse

CI

Transverse

CORD

Umbilical
Cord





Free floating loop of umbilical cord demonstrating
3VC



Iliac wings
Bladder
Color Doppler around bladder

Bladder/
Cord

Transverse

3VC

Bladder

Transverse

BLADDER


Iliac wings
Bladder

GENDER

(identify
male or
female)

Male
o Scrotum and penis
Female
o Labia

Gender

Transverse

HMP:\Protocols\OBGYN Protocols\2nd Trimester Protocol.docx

2nd and 3rd Trimester OB Protocol

Fetal Spine and Extremities
Organ/
Order

Scan Plane

Label

Landmarks Identified

CSP SAG

Skull, cervical spine, and upper thorax
o Sagittal view not available coronal is
acceptable, label accordingly

Sagittal

TSP SAG

Distal neck, thorax, and upper abdomen
o Sagittal view not available coronal is
acceptable, label accordingly

Sagittal

LSP SAG

Lower abdomen to lower point of LSP
o Sagittal view not available coronal is
acceptable, label accordingly

Transverse

CSP TX

Spine up-just below skull, skin line

Transverse

TSP TX

Spine up-mid thorax, rib, skin line

LS-SP TX

Spine up-iliac wings, skin line

RT HUMERUS

Shoulder, humerus and elbow


Elbow, ulna, radius and wrist
Wrist and fingers (open and closed)

LT HUMERUS

Shoulder, humerus and elbow

Longitudinal

LT ULNA/RADIUS

Elbow, ulna, radius and wrist connections

Longitudinal

LT HAND

Wrist and fingers (open and closed)

Longitudinal

RT FEMUR

Femur and knee

Lower Extremity Longitudinal

RT TIB/FIB

Knee, tibia, fibula and ankle
o FRONTAL View

Coronal

RT FOOT


Foot
Toes

Longitudinal

LT FEMUR

Femur and knee

LT TIB/FIB

Knee, tibia, fibula and ankle
o FRONTAL View

LT FOOT


Foot
Toes

Sagittal

Spine

Transverse
Longitudinal

Longitudinal RT ULNA/RADIUS
Longitudinal
RT HAND
Upper Extremity Longitudinal

Longitudinal
Coronal

HMP:\Protocols\OBGYN Protocols\2nd Trimester Protocol.docx

2nd and 3rd Trimester OB Protocol

Fetal Heart
Fetal heart images will vary from site to site. All students are responsible for completing a sweep
through the heart to determine situs, connection and recognize views

Organ/Order





Landmarks Identified
Right and left atrium
Foramen Ovale
Right and left ventricle
Tricuspid and Mitral Valves
Spine

(IVS Vertical)





Right and left atrium
Foramen Ovale
Right and left ventricle
Tricuspid and Mitral Valves
Spine

Superior Vena
Cava & Inferior
Vena Cava

Long axis
Sagittal fetal
chest



Inferior vena cava
Right atrium
Superior vena cava

Left Ventricular
Outflow Tract

Long Axis
Transverse
fetal chest



Left ventricle
Aortic valve
Aortic root



Proximal aorta
3 branches-innominate, left common carotid artery
& left subclavian
Thoracic aorta



Right ventricle
Pulmonary valve
Pulmonary trunk












RT ventricle
Pulmonary valve
RT pulmonary artery
LT pulmonary artery
Aorta
Aortic valve
Pulmonary trunk
Ductus arteriosus
Thoracic aorta
AO
SVC
DA

Subcostal
4 Chamber
View

Apical
4 Chamber
View

Aortic Arch

Right
Ventricular
Outflow Tract

Right
Ventricular
Outflow Tract

Ductus
Arteriosus Arch

3 Vessel View

Scan Plane
Transverse
fetal chest
(IVS
horizontal)
Transverse
fetal chest

Sagittal Fetal
Chest

Long Axis
Transverse
Fetal Chest

Short Axis
Transverse
Fetal Chest

Label

4CH
SUBCOSTAL

4CH
APICAL

SVC/IVC

LVOT

AA

RVOT

RVOT
SHORT

Sagittal Fetal
Chest

DA

Transverse
Fetal Chest

3 VESSEL
VIEW

HMP:\Protocols\OBGYN Protocols\2nd Trimester Protocol.docx

2nd and 3rd Trimester OB Protocol

Normal Measurement Ranges
Structure
Amniotic Fluid
Volume
Sum of 4 amniotic
fluid measurements

Area of Interest
Divide the
uterus into 4
quadrants and
measure the
largest vertical
pocket of
amniotic fluid in
each quadrant

Plane
Sagittal

Measurement
Greater than

20cm-abnormal 
Less than 5cmabnormal

*measurement
may vary per site

Amniotic Fluid
Largest Vertical
Pocket

Single

Sagittal

Greater than

10cm-Abnormal
Less than 2cm- 
Abnormal
*measurement
may vary per site

Comments
Patient should be supine
With the probe in the sagittal
position, locate the largest
pocket of amniotic fluid clear of
all fetal parts
Measure the fluid pocket from
anterior to posterior (at least
1cm)
Document this measurement
for each quadrant of the uterus.
Add the measurements for a
total
Measurement of the largest
single vertical pocket of fluid in
the uterus
Commonly used for twin
pregnancies

Cerebellum

Posterior Fossa
of the Brain

Sagittal

Equal to
gestational age

Move caudal from BPD. Head
must be symmetrical

Nuchal Fold

Skin thickness
on the posterior
head

Coronal

Normal
-less than 6mm
up to 24 weeks
gestation

Same plane as cerebellum
measurement

Cisterna Magna

Anechoic Space
in the Posterior
Fossa
Longest axis of
the kidney

Coronal

Normal

-less than 10 mm

Same plane as cerebellum
measurement

Amount of
cerebrospinal
fluid in ventricle

Coronal

Kidney Length

Lateral Ventricles

Sagittal

Approximately
equal to
gestational age
through 2nd
trimester

Long axis of the kidney measuring
from superior to inferior pole

Less than 10 mm 

HMP:\Protocols\OBGYN Protocols\2nd Trimester Protocol.docx

Superior to BPD at the level of
the ventricles
Measure at atrium or the
thickest portion of the choroid
plexus (CHP) or glomus

2nd and 3rd Trimester OB Protocol
Color and Spectral Doppler Analysis
Structure

Area of Interest

Plane

Umbilical Artery

Document
umbilical artery
blood flow with
Color Doppler and
Spectral Analysis
in a free loop of
the umbilical cord

Longitudinal

Document
umbilical artery
blood flow with
Color Doppler and
Spectral Analysis
in a free loop of
the umbilical cord
Lateral branches
of the circle of
Willis

Longitudinal

Umbilical Vein

Middle Cerebral
Artery

Normal
Measurement
S/D= less than 3
after 30 week
PI= less than 1.4
after 30 week

Coronal

Comments



RI-less than .7 after
30 weeks

2nd-3rd trimester=
Continuous
forward flow with
increasing mean
velocities until 37
weeks

PI= More than 1.4
before term

Less than 1 by term
(Decreases after 32
weeks)



**MCA(RI)/UA(RI)=
greater than 1
Ductus Venosus

Shunt between
the umbilical vein
and inferior vena
cava

Transverse
Abdomen

Peak velocity=
50 cm/sec




Angle correct is not needed
Low resistive wave form
High end diastolic flow is
normal
Absence of diastolic flow
indicates fetus is in distress
Reversal of diastolic flow is
severe and seek immediate
help from physician
Pulsations can indicate a
severe condition
Fetal breathing movements
will alter continuous forward
flow pattern

Found slightly caudal to BPD
plane
Same proximal end
Position the head to achieve
a Doppler angle of zero or as
close as possible
High impedance flow with
low diastolic flow
Abnormal flow will display
high diastolic flow
Indicate pre-eclampsia, IUGR
& anemia
High diastolic component
Evaluate the “A” waveabnormal if less than
5cm/sec

Laboratory Values
 Qualitative hCG-urine pregnancy test, results positive or negative
 Quantitative hCG- blood pregnancy test, results indicate possible age of pregnancy
 Alpha Fetoprotein (AFP)-blood test for detection of certain abnormalities at 15-20 weeks
 High indicates open neural tube defect
 Low indicates Down syndrome
 Abnormal in cases of wrong dates, fetal demise or twins
 Triple Screen or Quad Screen-combination of blood test including AFP, unconjugated estriol (uE3), hCG, and
Inhibin A (Quad screen)
 Used to detect chromosome abnormalities
Pathology
 Gray scale sagittal and transverse images including images with 3 measurements (length, width and height)
 Color Doppler image document the presence of blood flow
 Spectral Doppler image document type and velocity of blood flow

HMP:\Protocols\OBGYN Protocols\2nd Trimester Protocol.docx