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/ Scan Label Landmarks Identified

Order Plane
Begin at cervix, move superiorly out of uterine fundus
o Identify the fetus within the uterus
NO IMAGE-SCAN
TX o Identify number of fetuses
THROUGH
o Identify fetal lie
o Determine the right and left sides of the fetus
Uterus/
TX HEART RATE Fetal heart and chest
Fetus
o Enlarge image of heart and document heart rate
with M-mode or Spectral Doppler
TX HEART RATE Fetal heart and chest
o Enlarge image of heart and document heart rate
with a cine-loop
Uterine Sagittal CERVIX ML Vaginal Canal
Cervix Cervix
Amniotic Sac
Sagittal CERVIX ML Vaginal Canal
Cervix
Amniotic Sac
Measure Cervical Length
o External os to internal os
Sagittal FETAL LIE Document presenting fetal structure
Cervix
o Indicate Breech or Vertex in annotation
Sagittal ADNEXA SAG RT RT Adnexa include ovary if possible
Adnexa
Sagittal ADNEXA SAG LT LT Adnexa include ovary if possible
PLACENTA Placenta closest to Cervix
Sagittal
SAG INF Retroplacental complex
PLACENTA Placenta Mid- include cord insertion
Placenta Sagittal
SAG MID Retroplacental complex
PLACENTA Placenta- superior portion
Sagittal
SAG SUP Retroplacental complex
Amniotic Q1 Measure largest vertical pocket clear of fetal components
Sagittal
Fluid Index from Anterior to Posterior
(volume) Q2 Measure largest vertical pocket clear of fetal components
Q1+Q2+Q3 Sagittal
from Anterior to Posterior
+Q4= AFI Q3 Measure largest vertical pocket clear of fetal components
Sagittal
from Anterior to Posterior
*Structures Measure largest vertical pocket clear of fetal components
seen in each Sagittal from Anterior to Posterior
pocket will Q4
vary

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Fetal Measurements
Structure/ Scan Label
Order Plane Landmarks Identified
Cavum septum pellucidum, IHF, Thalami and Parietal
bones
Fetal BPD Measurement technique
Measurements 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
HC 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
Trans
CEREBELLUM Measurement technique
Axial
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
CISTERNA Measurement technique
MAGNA 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
NUCHAL FOLD
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
Abdomen Measurement technique
AC
TX 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
Long
FL o Place calipers from end to end on the femur -
Bone
Do not include epiphysis point
o Calipers should dissect the middle of the bone
Humerus bone with distal or end shadowing
Measurement technique
Long o Place calipers from end to end on the
HL
Bone humerus-Do not include epiphysis point
o Calipers should dissect the middle of the bone

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Fetal Head and Face Structures

Organ/ Scan Plane Label Landmarks Identified

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

Fetal Head VENTRICLES IHF

Transaxial (indicate Ventricles
RT & LT)

IHF
VENTRICLES Ventricle
(indicate Measurement Technique
RT & LT) o Posterior ventricle
o Measure internally lateral to medial at glomus

Fetal Face Face FACE Orbits

Coronal Mandible

LENS Orbits
Echogenic lens (can be in transaxial plane)

NOSE AND LIPS Nostrils

Upper lip

Face PROFILE Forehead, nose, extended chin and neck

Midline
Sagittal

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Fetal Thorax, Abdomen and Pelvic Structures

Organ/ Scan Plane Label Landmarks Identified
Order
RT lung
DIAPHRAGM Diaphragm
Sagittal
RT Liver
Thorax/
Abdomen
LT lung
Sagittal DIAPHRAGM Diaphragm
LT Stomach

Stomach
STOMACH
Stomach Transverse Transverse spine

Transverse spine
Right kidney
Transverse KIDNEYS
Left kidney

Left Sagittal Kidney (can be taken in coronal)

Kidneys
Sagittal RK SAG Measurement technique
o Superior to inferior border
Left Sagittal Kidney (can be taken in coronal)
Sagittal LK SAG Measurement technique
o Superior to inferior border
Transverse spine
Umbilical cord insertion into abdomen
Transverse CI Abdominal skin line
Umbilical Umbilical cord projecting from abdomen
Cord
Free floating loop of umbilical cord demonstrating
Transverse CORD 3VC

Iliac wings
Bladder/ Bladder
Transverse 3VC
Cord Color Doppler around bladder

Iliac wings
Bladder Transverse BLADDER Bladder

GENDER Male
o Scrotum and penis
Gender Transverse (identify Female
male or o Labia
female)

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Fetal Spine and Extremities

Organ/ Scan Plane Label Landmarks Identified

Order
CSP SAG Skull, cervical spine, and upper thorax
o Sagittal view not available coronal is
Sagittal
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

Spine
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

Transverse
Longitudinal RT HUMERUS Shoulder, humerus and elbow

Longitudinal RT ULNA/RADIUS Elbow, ulna, radius and wrist

Longitudinal RT HAND Wrist and fingers (open and closed)

Upper Extremity Longitudinal 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

Longitudinal o FRONTAL View

LT FOOT Foot
Coronal
Toes

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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 Scan Plane Label Landmarks Identified

Right and left atrium
Transverse
Subcostal Foramen Ovale
fetal chest
4 Chamber 4CH Right and left ventricle
View SUBCOSTAL Tricuspid and Mitral Valves
(IVS
horizontal) Spine

Right and left atrium

Apical Transverse Foramen Ovale
4 Chamber fetal chest 4CH Right and left ventricle
View APICAL Tricuspid and Mitral Valves
(IVS Vertical) Spine

Superior Vena Long axis Inferior vena cava

Cava & Inferior Sagittal fetal Right atrium
SVC/IVC
Vena Cava chest Superior vena cava

Left ventricle
Left Ventricular Long Axis
Aortic valve
Outflow Tract Transverse LVOT
Aortic root
fetal chest

Proximal aorta
Sagittal Fetal 3 branches-innominate, left common carotid artery
Aortic Arch
Chest AA & left subclavian
Thoracic aorta

Right Right ventricle

Long Axis
Ventricular Pulmonary valve
Transverse RVOT
Outflow Tract Pulmonary trunk
Fetal Chest

RT ventricle
Right Pulmonary valve
Short Axis
Ventricular RVOT RT pulmonary artery
Transverse
Outflow Tract SHORT LT pulmonary artery
Fetal Chest
Aorta
Aortic valve
Ductus Pulmonary trunk
Sagittal Fetal DA
Arteriosus Arch Ductus arteriosus
Chest
Thoracic aorta
AO
Transverse 3 VESSEL
3 Vessel View SVC
Fetal Chest VIEW
DA

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Measurement Ranges

Structure Area of Interest Plane Measurement Comments

Amniotic Fluid Divide the Sagittal Greater than Patient should be supine
Volume uterus into 4 20cm-abnormal With the probe in the sagittal
quadrants and position, locate the largest
Sum of 4 amniotic measure the Less than 5cm- pocket of amniotic fluid clear of
fluid measurements largest vertical abnormal all fetal parts
pocket of Measure the fluid pocket from
amniotic fluid in *measurement anterior to posterior (at least
each quadrant may vary per site 1cm)
Document this measurement
for each quadrant of the uterus.
Add the measurements for a
total

Amniotic Fluid Single Sagittal Greater than Measurement of the largest

Largest Vertical 10cm-Abnormal single vertical pocket of fluid in
Pocket the uterus
Less than 2cm- Commonly used for twin
Abnormal pregnancies
*measurement
may vary per site

Cerebellum Posterior Fossa Sagittal Equal to Move caudal from BPD. Head
of the Brain gestational age must be symmetrical

Nuchal Fold Skin thickness Coronal Normal Same plane as cerebellum

on the posterior -less than 6mm measurement
head up to 24 weeks
gestation

Cisterna Magna Anechoic Space Coronal Normal Same plane as cerebellum

in the Posterior -less than 10 mm measurement
Fossa
Kidney Length Longest axis of Sagittal Approximately Long axis of the kidney measuring
the kidney equal to from superior to inferior pole
gestational age
through 2nd
trimester

Lateral Ventricles Amount of Coronal Less than 10 mm Superior to BPD at the level of
cerebrospinal the ventricles
fluid in ventricle Measure at atrium or the
thickest portion of the choroid
plexus (CHP) or glomus

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Color and Spectral Doppler Analysis

Structure Area of Interest Plane Normal Comments

Measurement
Umbilical Artery Document Longitudinal S/D= less than 3 Angle correct is not needed
umbilical artery after 30 week Low resistive wave form
blood flow with High end diastolic flow is
Color Doppler and PI= less than 1.25 normal
Spectral Analysis after 30 week Absence of diastolic flow
in a free loop of indicates fetus is in distress
the umbilical cord RI-less than .7 after Reversal of diastolic flow is
30 weeks severe and seek immediate
help from physician
Umbilical Vein Document Longitudinal 2nd-3rd trimester= Pulsations can indicate a
umbilical artery Continuous severe condition
blood flow with forward flow with Fetal breathing movements
Color Doppler and increasing mean will alter continuous forward
Spectral Analysis velocities until 37 flow pattern
in a free loop of weeks
the umbilical cord
Middle Cerebral Lateral branches Coronal PI= Found slightly caudal to BPD
Artery of the circle of plane
Willis Greater than 1.45 Same proximal end
before term Position the head to achieve
a Doppler angle of zero or as
Less than 1 by term close as possible
(Decreases after 32 High impedance flow with
weeks) low diastolic flow
Abnormal flow will display
high diastolic flow
Ductus Venosus Shunt between Transverse Peak velocity= Indicate pre-eclampsia, IUGR
the umbilical vein Abdomen 50 cm/sec & anemia
and inferior vena High diastolic component
cava Evaluate the “A” wave-
abnormal 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

MR: Foundations\OBGYN\Lab\Protocols\ 2nd Trimester Protocol.docx