Learners' Guide Final Arrangement. Rajiv and Punam (00000002)

Rural Obstetric Ultrasound
Training For Nurses
Learners' Guide
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Table of Contents
Introduction 1
Background................................................................................................................................................1
Course Description.....................................................................................................................................2
Course Goal...............................................................................................................................................2
Core Competencies....................................................................................................................................2
Course objectives.......................................................................................................................................3
Training Approach 4
Training methods.......................................................................................................................................4
Training materials......................................................................................................................................4
Learner selection criteria............................................................................................................................4
Training sites..............................................................................................................................................4
Methods of assessment..............................................................................................................................5
Ethical Considerations6
DECLARATION FORM 8
Communication Skills 9
Concepts of communication......................................................................................................................9
Types of communication............................................................................................................................9
Verbal communication:...........................................................................................................9
Non-verbal communication:....................................................................................................9
Written communication:........................................................................................................10
Barriers of effective communication in healthcare..................................................................................10

Techniques of effective communication..................................................................................................11
Counseling...............................................................................................................................................12
Basic Skills of counseling-....................................................................................................12
Non-Verbal Communication Skills.......................................................................................12
Verbal communication skills.................................................................................................13
Breaking Bad News.................................................................................................................................15

Course Schedule 17
ANNEX 1 Training Registration Form 22
ANNEX 2 Pre Course Knowledge Assessment Questionnaire 23
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ANNEX 3 Case Scenario 1 25
ANNEX 4 Basic Skill Checklist 27
ANNEX 5 Quality of Ultrasound Images 29
ANNEX 6 Ultrasound Images of Different Modes 29
ANNEX 7 Anatomical Images of Female Pelvic Structures 30
ANNEX 9 Module 1 Knowledge Assessment Test 32
ANNEX 10 Skill Checklist for First Trimester37
ANNEX 12 Module 2 Knowledge Assessment Test 40
ANNEX 14 Skill Checklist for Second and Third Trimester 44
ANNEX 16 Knowledge Assessment Test for Module 347
ANNEX 17 Post Course Knowledge Assessment Questionnaire 50
ANNEX 18 Checklist for Effective Counseling 54
ANNEX 19 Checklist for Breaking Bad News 55
ANNEX 20 Log Book 56
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Introduction
Background
Constitution of Nepal has ensured the reproductive health right of all Nepalese women. Safe
motherhood is one of the key components of reproductive health.
Ultrasound has become a very necessary diagnostic tool in modern medical practice. As it is
cheap, readily available, safe and less technically demanding compared to other modalities, use
of diagnostic ultrasound is rapidly increasing even in low and middle income countries.
In obstetric practice, ultrasound is like an eye to watching fetal and maternal conditions. Timely
detection of any pregnancy related problems are likely to prevent adverse perinatal outcome. Due
to its easy availability, affordability, noninvasiveness and proven safety to the growing embryo,
its use in obstetrics is rampant throughout the world.
Developed countries are already providing at least one or more scans during pregnancy to
almost 100% of population. However, the situation is not the same in low and middle income
countries. There are various obstacles in the health system of these countries to provide obstetric
ultrasound service. In context of Nepal, health facilities and experts are mostly concentrated in
urban cities and large part of population residing in rural areas is deprived of specialized health
care.
Government of Nepal has launched various public health programs to reduce maternal and
neonatal mortality under safe motherhood program. Rural Obstetric Ultrasound Program (RUSG
Program) is one of the priority programs under safe motherhood targeting the pregnant women of
rural Nepal. This program was initiated as a result of a pilot intervention program conducted in
Dhading district from June 2011 to July 2012. Few nurses were trained to perform obstetric
ultrasound by ministry of health and population, (MoHP) Nepal and Nepal Health Sector Support
Program (NHSSP). As per the recommendation of this intervention program, Rural Obstetric
Ultrasound Program was launched by the MoHP, Nepal with an aim to provide obstetric
ultrasound to rural women by training nurses who are working as skilled birth attendants in the
rural public health institutions.
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Course Description
The Rural Obstetric Ultrasound course is designed to train nurses who are working or to be
working in the birthing centers where no obstetric scanning facility is available. The training is
on-site clinical training in which participants get enough practice on simulation and real clinical
cases for competency development so that they can perform quality obstetric scanning services
to rule out obstetric complication and timely referral.
National Health Training Centre has developed this training package for nurses working in
birthing centers and maternity unit of remote health set-ups where obstetric scanning facility is
not available. This course focuses on helping the nurses acquire basic scientific knowledge so
that they can better take care of pregnant women with obstetric complication. Knowledge, skills
and attitude developed through this course is expected to enable participants collaborate in the
provision of essential management to pregnant mothers by identifying major obstetric
complications and early and plan for timely referral to CEONC center.
Course Goal
The goal of this course is to prepare competent rural nurses who are able to identify pregnancy
related complications for timely referral to appropriate health institution.
Core Competencies
The desired competencies required by a nurse to perform basic obstetric scan and interpret the
common obstetric complications are –
1. Operation and maintenance of the portable ultrasound unit
2. Application of basic obstetric scanning techniques
3. Identification of intrauterine gestation
4. Identification of fetal Presentation/lie
5. Establishment of fetal viability
6. Perform fetal biometry to calculate gestational age and expected fetal weight.
7. Identify normal placenta and detect abnormalities
8. Quantify amniotic fluid and identify abnormalities
9. Maintain records and report to appropriate facilities
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10. Make appropriate and timely referral for needful obstetric complications
Course objectives
By the end of this course participants will be able to :
1. identify their role and maintain ethical consideration while providing the service
2. describe general structure and parts of a portable ultrasound unit
3. identify and operate obstetric knobology (Functions of obstetric keys )
4. care portable ultrasound unit and its parts
5. identify and manage common troubles
6. apply basic transabdominal obstetric scanning techniques
7. identify normal female pelvic structures (bladder, uterus and adnexa)
8. identify and localize gestational sac
9. identify Cardiac activity
10. use M- Mode scanning to record fetal heart rate
11. identify fetal head, fundus of uterus and Internal Os
12. interpret fetal presentation
13. measure CRL /GSD,BPD,HC,AC and FL
14. identify normal placenta and lower placental edge
15. carry out simple amniotic fluid survey
16. calculate and interpret amniotic fluid index
17. provide effective counseling for timely and appropriate referral
18. document the records and report to the concern facilities
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Training Approach
Training methods
Class room based knowledge transfer / update, skills demonstration and practice in simulation
followed by real practice in clinic using the following methods -
1. Interactive presentations
2. Discussion
3. Case studies and role plays
4. Demonstration
5. Skills practice with coaching and feedback
6. Video and images
Training materials
1. Reference manual
2. Participant’s handbook and
3. Images /photoset, video
4. Facilitator guide for facilitators
5. Power point presentations for facilitators
Learner selection criteria

Learners of this course must fulfill the following criteria
 Nurses with skilled birth attendant training from the remote health facilities where no
obstetric scanning facility is available.
 The facility must have portable ultra sound unit.
 The learner who are allowed and willing to carry portable ultrasound unit for training.
 The learner of this course must have passion and commitment towards providing this
service.
 The learner must be motivated to provide outreach service if indicated.
Training sites
 The training sites are selected hospitals that have been accredited by national health
training center.
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 The training sites must have the minimum facilities mentioned in annex-1
Methods of assessment
1. Knowledge assessment by using pre and post course questionnaire
2. Skills assessment using a checklist and clinical log books
3. Attitude (professionalism) assessment by using role plays
4. Decision making skills using case studies
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Ethical Considerations
Diagnostic ultrasound is a specialized field of medicine that requires formal academic training of
certain duration. In Nepal, Nepal Medical Council registered radiologists are only legally
authorized to practice diagnostic ultrasound and provide a report with expert opinion. Nepal
Medical Council registers those who have passed at least three years of masters degree in
radiology after MBBS, from a recognized institution or university after taking a specialty
registration examination.
In a country like Nepal, where specialized health man power are not available in rural areas, the
concept of task shifting in health helps to fulfill the gap in human resource for health to some
extent. The available human resource for health in rural birthing centers perform
multidisciplinary works in their respective centers. Most of the obstetrical cases are handled by
nurses. So it somehow seems logical to shift the task of rural obstetric ultrasound to these nurses.
However, many ethical dilemmas arise in this context. Some of them are:
1. Specialized services like diagnostic ultrasound is difficult to consider for task shifting as
it requires high level of academic training.
2. Minimum academic qualification of nurses to be able to learn the technically demanding
obstetric ultrasound.
3. Short term training may not be sufficient for nurses to perform obstetric ultrasound
independently.
4. There may be some legal issues regarding the authentication of report provided by nurses.
5. Chances of misuse of training by nurses.
6. Provision for certification and continuing education to nurses providing obstetric
ultrasound services.
7. Provision of alternatives while the trained nurse is on leave, goes for higher education or
is transferred.
8. Legal issues associated with misdiagnosis, wrong diagnosis and their consequences.
9. Legal issues associated with inability to diagnose or identify fetal abnormalities.
10. Legal issues associated with fetal gender determination and sex selective abortion.
There are plenty of similar ethical dilemmas. They can never be completely avoided, but to some
extent, they can be minimized. Some basic steps to minimize these ethical dilemmas are:
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1. A balanced system of training and service should be established.
2. A strict training and service regulatory package to establish norms for training sites,
trainers, trainees and service center.
3. Evidence based minimum requirement for nurses to participate in training.
4. Strong certification system with clearly defined do's and don'ts after receiving the
training.
5. Clear guidelines for training site certification, trainer certification and uniformity of
training at all training sites.
6. Orientation of trainees to ethical and legal issues during training.
7. Practice of de-certification in case a trainee is found breeching the regulations of the
program.
8. Aptitude test of the trainees before and after training program.
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DECLARATION FORM
I have read well, the ethical considerations including Do's and Don'ts of the Rural Obstetric
Ultrasound Training. The facilitators have well explained to me about ethical issues of providing
obstetric ultrasound service in rural health set ups. I am well aware of the major ethical issues of
the program and, I promise on following points:
1. I will provide free obstetric ultrasound service at specified government health set ups
only.
2. I will not claim any monetary benefits based on the number of service seekers.
3. I will provide service to outreach centers, as required, based on communication with
health section of palika.
4. I will not provide obstetric ultrasound service at any private centers.
5. I will not misuse my certificate by any means.
6. If I resign from government service, I accept the auto-cancellation of my training
certificate.
7. In case of breech of ethical consideration of the program, I will accept any form of
departmental action.
8. I am willing to be bound by all the rules and regulations of RUSG Program at present and
in future.
I, hereby, declare that I am willing to be bound by all the ethical considerations of this program
and signing this declaration form, voluntarily.
..............................................................
.
(Signature)
Name:
Karmachari Sanket Number:
Health Institution:
Post/Designation:
Date:
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Communication Skills
Concepts of communication
Communication is defined as a two-way process involving speech, writing or non-verbal means
that aim to create shared interpretation for those involved. Effective communication between
health professionals and patients is the key component to a safe, and quality healthcare system. It
is also responsible for building a satisfactory and conducive relationship between all stakeholders
of the healthcare system. In this way it helps in building safe, trustworthy, supportive, and
professional working environment.
Patient listening, empathy, and paying attention to the para-verbal and non-verbal components of
the communication are the important ones that are frequently neglected by the medical
professionals. Providing proper information about the nature, course and prognosis of the disease
to clients is very important in health care system. It should be ensured that information is
accurately passed on by the sender through media and received by the receiver.
Types of communication
Commonly there are three types of communication:
1. Verbal communication
2. Nonverbal communication
3. Written communication
Verbal communication:
Verbal communication is done using different sounds and words to express ourselves. It is used
not only for counseling, explaining, re-assuring the parents, patients and their relatives but also
for talking among health workers during discussion about the patients, hand-over processes etc.
Different persons deliver the same information differently and also can be understood differently
by different persons. Therefore, all the health workers need good verbal communication skills to
explain common conditions; investigations, procedures and treatment plan to parents.
Non-verbal communication:
It is a non-linguistic transmission of information through visual, auditory, tactile and body
language. This is one of the most important types of communication. Verbal communication
should match with non-verbal communication to make it effective. The following issues should
be taken in consideration to make non-verbal communication effective.
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 Gesture (Your expression, reaction)
 Posture of the body (How you sit or put your body parts, like cross leg, folding the hands)
 Body language (Body movements, hand movements, eye movements)
 Tone of the voice (Should be pleasing)
 Pitch of the voice (Modulation of voice according to the situation)
 Eye contact (Do not stare to the patient)
 Facial expression (Do not smile when you are breaking bad news)
 Time (Stick to time, do not repeat the same thing again and again)
 Personal presentation (Wear dignified clothing during communication)
Written communication:
It is the ways of delivering messages in the writing form. Health workers use this form of
communication during writing of progress notes, records of the hemodynamic trends of the
patients, prescription order given by treating physicians, consultation request, laboratory reports,
report of radiological investigation, bedside procedural notes, admission note, and discharge note
and during obtaining the consent. This type of communication is also very important for the
documentation for legal process. So, one should be cautious in writing notes.
The communication skills for health professionals are very crucial especially during the
following situations.
 Obtaining consent
 Breaking bad news
 Dealing with the angry patient or relative
 Dealing with the anxious or upset patient or relative
 Discharge planning and negotiation
Remember - Communication is not just saying something
Barriers of effective communication in healthcare

There are several barriers of communication and some important ones are as follows:
 Time constraints for communication
 Environmental issues such as noise, privacy during the communication
 Pain and fatigue of the health professionals and clients
 Embarrassment and anxiety as perceived by the clients
 Use of medical jargons used by the health professionals
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 Values and beliefs of stakeholders
 Information overload to client
Techniques of effective communication

The health workers should know what to do, how to do and what not to do during
communication as follows:
What to do
 Introduce yourself
 Summarize the patient’s presenting symptoms
 Tell the patient what are we going to explain
 Determine how much the patient already knows
 Determine how much the patient would like to know
 Elicit the patient’s main concerns
 Deliver the information
 Summarise and check understanding
 Encourage and address questions
How to do
 Be empathetic
 Explore the patient’s feelings
 Give the most information first
 Be specific
 Check understanding regularly
 Use simple language and short sentences and explain in Layman’s terms
 Use diagrams if appropriate
 Hand out a leaflet if present
 Be honest: If we are unsure, tell later after consultation with others etc.
What not to do
 Hurry
 Reassure too soon
 Be patronising
 Give too much information
 Using medical jargons
 Confabulate (make things up)
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Counseling
It is a process of intervention between counselee and counselor to assist the counselee to alter,
improve or resolve present behavior, difficulty or discomforts. It is about strengthening the
ability of counselee in dealing with problems, feelings, worries and discovering- developing
coping mechanisms.
One who provides counseling - Counselor
One who takes service – Counselee /Client
Basic Skills of counseling-

 Active listening
 Non-verbal Communication
 Verbal communication
Non-Verbal Communication Skills
SOLER
S- Sitting position
Sitting in ‘L’ or 90° position and in equal level is considered appropriate sitting position for
counseling.
O- Open posture
Crossed arms and legs give sign of less involvement. Open posture gives clue that counselor is
open to client and to what s/he has to say.
L- Lean forward
A slight inclination towards a person often indicates ‘I am with you, I am interested what you
have to say’.
E- Eye contact
Frequent and soft eye-contact make client to feel attended. It should be less in initial session and
more eye contact can be maintained with rapport and progression of session. Cultural practice
should be maintained with this behavior.
R- Relaxed
Seeing a relaxed counselor help client to be relaxed and also if counselor is relaxed he can think,
focus and understand the client better.
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Verbal communication skills
Exchange of messages through words or phrases which has contents of what we are talking about
and words that are spoken.
Skills: -
1. Rapport building
2. Questioning
3. Empathy
4. Paraphrasing
5. Repeating key words
6. Reflection of feeling
7. Summarizing
Rapport building
This is initial and most important skill for counseling where counselor takes initiation to talk, be
familiar and build trust with patient.
Questioning
It is a major component of active listening. It provides a systematic way of understanding and
accepting, feeling by exploring, clarifying and further defining some issues of client. Basically
three types of questions are used in counseling-
Closed questions
Open questions
Suggestive question
But ‘Why?’ question is not suggested to use
Empathy
Empathy is the active practice of feeling into the inscape of client, but counselor must be careful
not to push too hard or fast while using this skill.
Paraphrasing
It is to repeat in short a client’s statement in own words. It invites client to confirm statement,
enabling to check if understood content correctly. It focuses on immediate statements without
adding or altering to meaning of client’s statement.
Repeating key words
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Counselor repeats words or part of sentence that the client has just said. This repetition should be
of emotionally charged or important in content. It encourages client to continue talking and helps
to give emphasis to particular topic.
Reflection of feeling
Counselor listens, observes carefully to expressed and unexpressed feeling of client and reflect
his/her understanding back to client.
Summarizing
Repeating client’s words but for longer time and with more information.
Enumerating key thesis, recapitulation of conversation and reformulating longer statement to
shorter, more direct form. It helps to maintain dialogue, secure clearness, and give room to check
whether counselor have understood correctly.
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Breaking Bad News
Bad news is “any news that adversely and seriously affects an individual's view of his or her
future” (Buckman 1984). All bad news, therefore, has serious adverse consequences for patients
and families (Fallowfield 1998, Ptacek 1996). Hence, breaking bad news is a very sensitive
process and we need, skills, training and experience for a proper delivery of bad news. We have
to be very cautious during breaking the bad news. We should know what to do, how to do and
what not to do during this process. However, the techniques for breaking bad news should be
individualized.
The S-P-I-K-E-S mnemonic is a useful technique (protocol) to be practiced in day-to-day
practice in the PICU and other wards or clinics while breaking the bad news to the parents or
other relatives.
S – SETTING: Secure an appropriate area for the discussion.
P – PERCEPTION: Assess the patient’s understanding of the seriousness of their condition.
I – INVITATION: Get permission to have the discussion.
K – KNOWLEDGE: Explain the facts.
E – EMOTIONS: Be Empathic, Be supportive.
S–STRATEGY & SUMMARY: Close the interview by summarizing the conversation and
checking the understanding.
The health workers can use the sequence of what to do, how to do and what not to do while
breaking the bad news as in other situations to communicate with the caregivers and among
themselves.
What to do
 Introduce ourselves
 Look to comfort and privacy
 Elicit what the caregiver already knows
 Determine what the caregiver would like to know
 Give hints to the client / caregiver that bad news is coming
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 Break the bad news
 Identify the caregiver’s main concerns
 Summarize and check understanding
 Offer realistic hope
 Arrange follow up
How to do
 Be sensitive
 Be empathetic
 Maintain eye contact
 Give information in small chunks
 Repeat and clarify
 Check understanding regularly
 Give the caregiver time to respond
 Do not be afraid of silence or of tears
 Explore the caregiver’s emotions
 Use physical contact if this feels natural to us
 Be honest
What not to do
 Hurry
 Give all the information in one go or give too much information
 Use medical jargons
 Lie or be economical with the truth
 Be blunt
Words are like loaded pistols

Jean-Paul Sartre
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Course Schedule
Time Activities and Contents
Day -1
 Opening and welcome-
 Introduction, participants expectations
 Course overview – goal ,core competencies objectives
3 hours  Daily activities
 Registration and document collections
 Pre course knowledge assessment and review
 Course material overview
 Orientation on Training site – place , norms (rules) of the
institution
 Overview of RUSG program and Ethical consideration
(SESSION 1)
45 mins Lunch break
Basics of ultrasound unit (SESSION 2)

 Fundamentals of ultrasound.
3 hours
 Basic physics of ultrasound.
 Basic instrumentation handling and
 Care of portable USG machine
Skill practice (SESSION 3)
15 mins  Summary of the day
Day-2
3 hours
Agenda and review of previous day
Knobology (SESSION 4)
 Obstetric knobology
 Introduction to knobs and basic functions
45 mins Lunch Break
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3 hours Basics of Obstetric imaging (SESSION 5)

 Basics of image formation
 Improving image quality
 Modes of scanning
 Planes of scanning
 common trouble shoots encountered in ultrasound
Skills practice Session (SESSION 6)
15 mins  Summary of the day

3 hours Day 3
Agenda and review
 Sonological orientation of female pelvic organs (SESSION 7)
Skill Practice Session(Practice in simulation) (SESSION 8)
45 mins Lunch Break

3 hours
Scanning of Normal First Trimester of Pregnancy (SESSION 9)- 45
mins
Skills Practice Session (SESSION 10) – gestestional sac, yolk sac,
embryo GSD CRL – 135 mins
15 mins Summary
Day 4
Agenda & review
Identification common abnormalities of first trimester of pregnancy
(SESSION 11)
 Abortion
 Ectopic pregnancy (ruptured tubal ectopic preganancy)
 Molar pregnancy
45 mins
Lunch Break
3 hours Skill Practice Session (SESSION 12)
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 Identification of Cardiac activity

 Missed Abortion/IUFD- No cardiac activity
 Practice with real client
15 mins Summary of the day
3 hours Day 5
Agenda and review
Evaluation of 2nd and 3rd trimester pregnancy
Identification of fetal Presentation/lie (SESSION 13)
 Identification of fetal head
 Fundus of uterus
 Internal os
 Interpret fetal presentation
 Demonstration and practice in real cases
Fetal Viability (SESSION 14)
 Heart localization, fetal parts movement identification
 Normal range FHR
 Ultrasound features of IUFD.
45 mins Lunch Break
3 hours Skills Practice Session (SESSION 15)
3 hours Day 6
Fetal biometry (blended with presentation and case based scenario)
(SESSION 16)
 Head Measurement
 Abdominal measurement
 Femur measurement
45 mins Lunch Break
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3 hours Day 7
Agenda and review
Placental localization (SESSION 18)

 Identification of normal placenta
 Identification of Lower placental edge
45mins Lunch Break
180 mins Day 8

Agenda and review
Amniotic Fluid Estimation (SESSION 20)
45 mins Lunch Break
3 hours Day 9
Agenda and review
 Recording and Reporting/ Use of Logbook (SESSION 22)
45 mins
Lunch Break
3 hours Day 10
Agenda and review
 Documentation( recording and reporting) and service readiness

 Final knowledge assessment
 Result discussion
 Review of previous session
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45mins Lunch Break

3 hours Skill Practice Session

6 hours Day 11- day 19
Practice in clinic
Day 20
6 hours  Final skill assessment
Day 21
 Course evaluation
6 hours  Action planning
 Closing
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ANNEX 1 Training Registration Form
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ANNEX 2 Pre Course Knowledge Assessment Questionnaire
Mark the following statements as True (T) or false (F).
Q.N. Statements Mark
1. First trimester pregnancy is regarded upto 20 weeks of 1.
gestation.
2. Gestational sac and yolk sac are different structures. 2.
3. Implantation occurring outside the uterine cavity is 3.
termed as ectopic pregnancy.
4. Per vaginal examination (PV) is absolutely 4.
contraindicated in first trimester bleeding.
5. Dark brown bleeding with passage of "grape like cysts" 5.
occurs in molar pregnancy.
6. Presence of gestational sac without yolk sac or embryo 6.
within it is termed as missed abortion.
7. Pregnancy can be continued after the diagnosis of 7.
threatened abortion.
8. Retained products of conception is seen in incomplete 8.
abortion.
9. Placenta is formed from fetal component only. 9.
10. Fundal placenta is called placenta previa. 10.
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11. When the fetal head is seen in relation to uterine fundus, 11.
fetal presentation is cephalic.
12. Internal Os is related to uterine cervix. 12.
13. The potential space posterior to urinary bladder and 13.
anterior to rectum is called Pouch of Douglas.
14. Absent fetal heartbeat confirms intra uterine fetal death. 14.
15. Excess liquor within the amniotic cavity is termed as 15.
oligohydramnios.
16. Presence of blood within the peritoneal cavity is termed 16.
as hemoperitoneum.
17. Painless PV bleeding during the third trimester of 17.
pregnancy is most likely due to placenta previa.
18. A nurse trained and certified in RUSG Program can 18.
perform obstetric ultrasound in a private clinic.
19. Effective communication and good counselling skill are 19.
important in providing rural obstetric ultrasound
service.
20. Rural Ultrasound training is not a professional course. 20.
21. Ultrasound uses X-ray to form an image. 21.
22. Ultrasound has bad effect on both the fetus and mother. 22.
23. Fetal weight can be estimated by ultrasound during 23.
second and third trimester.
24. Folic acid prevents neural tube defects. 24.
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25. Ventricles of the brain is filled by blood. 25.
ANNEX 3 Case Scenario 1

Anima a SBA trained nurse working in a rural health facility of eastern Nepal was hard working,
keen to learn new things and very humble to her clients. She was providing MNH service in her
health institution. At her workplace, she was very helpful and empathetic to pregnant women. She
had excellent counseling skill. Her decision making was outstanding. To update herself, she always
communicated with her trainers, teachers and other resource persons. Besides, she had tendency to
be updated with new information by literature review.
During the course of time, Anima got an opportunity to participate in rural obstetric ultrasound
training. The trainers were highly impressed by her motivation and hard work. She successfully
completed the training and was awarded to be an outstanding learner.
After training when she got back to her work place, she started providing basic obstetric scanning
service to her clients. She always stayed in touch with her trainers through social medias. She used
to share the images she obtainer and her provisional diagnosis to her trainers. Her diagnostic
accuracy in obstetrics was praised by her trainers. She identified a lot of obstetric complications
and referred them timely.
During the course of time Anima learnt to scan other abdominal organs besides obstetric scanning.
She identified other pathologies, too.. She became very popular in the community due to her good
nature. She was awarded with an outstanding service provider from her Palika executive.
Day by day, Anima was more popular nurse in her community. Considering her popularity and skill,
a local pharmacist planned to run a profit-based business utilizing her skill. He proposed Anima
help him run a private clinic. Initially Anima denied him. The pharmacist tried to convince her how
she could earn a lot of money with her skills in a private clinic. Later, Anima was influenced with
the idea of the pharmacist and she agreed to his proposal, somehow. She started working at his
clinic and earned a fair amount of money. The hunger of earning more money grew day by day and
Anima didn't have enough time to work for her health institution and community. She was mostly
busy at the private clinic even at her office hours.
Anima thought of practicing gender determination of fetus by different means to make more money.
She started the illegal service of gender determination of fetus with the help of the pharmacist.
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After few months someone from her community complained the government officials in the district
regarding illegal things being carried out in the clinic. Anima was arrested from the clinic and kept
in the police custody. Her certificate for performing basic obstetric ultrasound within her health
institution was cancelled by the authority. She was suspended from her job. Now people of her
community no more liked her as before. She has been demoralized in her society. Now she is
regretting on her past. Though, she could resume her job after few months of legal procedure, the
whole scenario had changed. After all this, Anima took a transfer to a far-off health facility.
Answer the following questions:
 According to the story, what things went well with Anima and what things went wrong?
 Imagine yourself in place of Anima and think of the social scenario.
 How this could have been prevented?
 What is the moral of the story?
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ANNEX 4 Basic Skill Checklist
Rate the performance of each step or task observed using the following rating scale:
1. Needs Improvement: Step or task not performed correctly, out of sequence (if necessary), or
if omitted
2. Performed with some level of difficulty.
3. Competently performed: step or task performed efficiently and precisely in the proper sequence (if
necessary)
STEPS Performing first trimester pregnancy CASES

Getting Ready
1. Prepare the necessary equipment's
2. Greet the client with respect
3. Ask name, address, LMP and other required information (obstetric
history)
4. Pay attention to client’s comfort.
5. Identify bladder is full before procedure (woman should drink 1 liter of
water half hour to 1 hour before procedure). If its second and third
trimester advise her to empty bladder
6. Tell the woman what is to be done and encourage her to ask questions.
Listen to her and answer her question.
Position
7. Help the client lie down in supine position on examination table
8. Keep small towel over her pants
9. Select the appropriate transducer (Probe): For transabdominal obstetric
ultrasound (low frequency curvilinear(convex) probe is preferred).
Procedure (clinical skills)
10. Sit or stand comfortably to the client’s right side and adjust the position
of the monitor straight to your eye level.
11. Watch use coupling gel in adequate amount: not too much to make a
mess and not too little to make scanning difficult. Heated gel can be
used for patient's comfort.
12. Optimize the on-screen image by adjusting the machine parameters-
27
use appropriate frequency, optimize the depth of the image. If too small
depth is used, large part of the image is useless, and the required image
is displayed very small in size. So, optimize the depth of image so that
the area of interest fills up most of the imaging area. Adjust focus of the
machine to the area of interest so that it is optimally visualized.
13. Apply minimum pressure to the abdomen: Put the transducer gently and
move it smoothly. Too much pressure on transducer will press the fetal
parts and is also uncomfortable for pregnant woman.
14. Take an image from some part, look at the image and adjust the "gain"
frequency and depth "time gain compensation"(TGC) of the machine so
that the image formed on the screen is neither too bright nor too dark.
The gain is most frequently used knob in ultrasound. Frequently adjust
the gain to optimal level when you scan from one anatomical part to the
other.
15. Bring the target anatomical area in the center of the image.
16. Avoid possible artifacts.
Post procedure task
17. Ensure the probe is cleaned after procedure
18. Check the final report correctly and record all findings
19. Explain all findings to the client
Trainer’s comment:
Date & signature:
28
ANNEX 5 Quality of Ultrasound Images
Poor Quality Images- How can you say these images are of poor quality?
Good Quality Images- How can you say these images are of good quality?
29
ANNEX 6 Ultrasound Images of Different Modes
Name the mode of Image
30
ANNEX 7 Anatomical Images of Female Pelvic Structures
31
You are performing the transabdominal ultrasound of a very obese(fat) pregnant woman who
presented at 35 weeks of gestation at your center.
Answer the following questions.

1. Out of the following transducers(probes) which of the following would you use in this situation ?
a. Convex or Curvilinear probe operating on 5 to 8 MHz.
b. Convex or Curvilinear probe operating on 2 to 5 MHz
c. Linear probe operating on 5 to 12 MHz.
d. Sector probe operating on 3 to 6 MHz.
2. You see a very large anechoic area around the fetus during the scan. What can this anechoic area
be?
a. Placenta
b. Fetus
c. Amniotic fluid
d. Bleeding
3. A moving structure (heart) is seen in your scanning plane. which ultrasound mode will you use to
record heart rate?
a. M- mode
b. A- mode
c. B-mode
d. AB- mode
4. Your image is too dark to visualize in the screen. Which knob will you use to brighten the overall
image?
a. Depth knob
b. Frequency knob
c. Focus knob
d. Gain knob
5. In transverse scanning plane at the pelvis, you could see the fetal head. Where is the pointer of
your transducer(probe) facing?
a. towards patient's head
b. to the patient's right
c. to the patient's left
d. towards patient's legs
32
ANNEX 9 Module 1 Knowledge Assessment Test
Choose one best option and mark it as answer to each of the following questions.
1.Which of the following statements is correct ?
a. Sound waves are transverse waves.
b. Sound waves are longitudinal waves.
c. Sound waves are part of electomagnetic waves.
d. None of the above statements are correct.
2. Sound travels fastest in which of the following tissue types?
a. Soft tissue c. Air
b. Bone d. Fluid
3. Which of the following statements is correct?
a. Audible sound is in the range of 20 to
c. Infrasound is in the range of 20 to
20,000 hertz.
20,000 hertz.
b. Ultrasound is in the range of 20 to 20,000
d. None of the above
hertz. statements are correct.
4. Ultrasound is generated by
a. Diamond crystals
b. Graphite crystals
c. Mesoelectric crystals
d. Piezoelectric crystals
5. Convex transducer works on
a. higher frequency than linear transducer. b. Same frequency as compared to linear
transducer.
c. lower frequency than linear transducer. d. none of the above
6. Higher is the frequency of transducer,
a. higher is the depth of penetration.
b. lower is the depth of penetration.
c. lower is the resolution of image.
d. none of the above are correct.
33
7. Coupling gel is used in ultrasound
a. to lubricate the skin. b. to displace air between skin and
transducer.
c. to make the movement of d. to make the skin soft
transducer easier on skin.
8. TGC stands for

a. Trial gain compensation
b. Time goal compensation
c. True gain compensation
d. Time gain compensation
9. Which of the following is correct?
a. Transvaginal ultrasound provides higher resolution than
transabdominal ultrasound.
b. Transabdominal ultrasound provides higher resolution than
transvaginal ultrasound.
c. Both transabdominal and transvaginal ultrasound provide equal resolution.
d. Image resolution is of not much value in obstetric ultrasound.
10. The mark (notch or pointer) of the transducer points towards
a. patient's right. b. patient's head.
c. both a and b are correct. d. both a and b are wrong.
11. Bone in ultrasound appears
a. isoechoic.
b. hypoechoic.
c. anechoic.
d. hyperechoic.
12. Clear fluid in ultrasound appears as.....................in ultrasound.
a. isoechoic. b. anechoic.
c. heteroechoic. d. hypoechoic.
13. The most commonly used ultrasound knob to adjust image brightness is
a. frequency knob. b. depth knob.
c. gain knob. d. TGC knob.
14. Urinary bladder acts as..................................to visualize uterus in ultrasound.
a. acoustic impedance b. acoustic blockade
c. acoustic window d. acoustic power
15. Hyperechoic structures appear
a. white in the image. b. black in the image.
c. neither a nor b is correct. d. both a and b are correct.
16. Posterior acoustic shadow(distal acoustic shadow) is seen in case of?
a. cyst.
b. stone/calculus.
c. urinary bladder.
d. none of the above.
17. Artifacts in ultrasound are defined as?
a. any alterations in the image which do not represent an actual image of the examined
area.
b. anything in ultrasound that helps to make better diagnosis.
c. any desirable adjustment in ultrasound machine that helps to optimize image in screen.
d. any findings that are expected to occur during ultrasound imaging.
18. Which type of transducer (probe) is best preferred for transabdominal obstetric
ultrasound?
a. Sector probe.
b. Linear probe.
c. Convex probe.
d. endocavitary probe.
19. When frequency of the transducer(probe) is reduced...........................
a. depth of the scan field is also reduced.
b. depth of the scan field remain unchanged.
c. depth of the scan field is increased.
d. none of the above statements are correct.
20. Normal femur bone appears as
a. heteroechoic in ultrasound. b. hyperechoic in ultrasound.
b. c. hypoechoic in ultrasound. d. anechoic in ultrasound.
ANNEX 10 Skill Checklist for First Trimester
1. Needs Improvement: Step or task not performed correctly, out of sequence (if
necessary), or if omitted
3. Competently performed: step or task performed efficiently and precisely in the proper
sequence (if necessary)
STEPS Performing first trimester pregnancy CASES

Getting Ready
1. Prepare the necessary equipments
2. Greet the woman with respect and kindness
3. Ask her name, address, LMP and other required information
(obstetric history)
5. Identify bladder is full before procedure (woman should drink 1
liter of water half hour to 1 hour before procedure)
6. Tell the woman what is going to be done and encourage her to ask
questions. Listen to her and answer her queries.
7. Procedure (clinical skill)
8. Encourage woman to lie down in supine position on examination

table
9. Keep small towel above symphysis pubis
10. Select and prepare probe properly
11. Uses keyboard and screen functions properly
12. Record client’s identification in usg machine
13. Apply gel and place probe, keep uterus in center of screen
14. Systematically identifies uterus in longitudinal and transverse
views, taking appropriate images
15. Scans across pelvis (to rule out anomalies, masses, twins)
16. Measure gestational sac appropriately
17. Identifies yolk sac
18. Identifies fetal pole and cardiac activity
19. Measure CRL in longest view if embryo is seen.
20. Assure location of pregnancy is intrauterine
21. Post procedure task
22. Ensure probe cleaned after procedure

Date & signature:

21 Year old female presented to OPD with increasing lower abdominal pain. According
to her, her LMP was 4 days back and she is bleeding currently. Her previous cycles
were also irregular and this time she is having menses after about 50 days. She denies
being pregnant because she thinks that it's her 4th day of menses today. When urine
pregnancy test was done, positive result was obtained.
1. With this information, what is the next best thing to do?

a. give her folic acid and send home
b. do an ultrasound
c. repeat urine pregnancy test after 1 week
d. do blood investigation
2. On ultrasound, the uterus is empty and fluid is seen in POD. Which of the following
is not a possibility?
a. complete abortion
b. ectopic pregnancy
c. very early pregnancy
d. molar pregnancy
3. After 3 days, the patient again comes with severe pain and on ultrasound, there is
large amount of anechoic fluid in pelvis. What has happened?
a. product of conception has already been expelled
b. the women was not pregnant at all
c. the pregnancy is about to be aborted
d. ectopic pregnancy has ruptured
4. Where else do you see by ultrasound for presence of anechoic fluid?
a. Morrison's Pouch
b. Lieno-renal Pouch
c. Lesser Sac
d. between the liver and left kidney
5. This anechoic fluid in the abdomen and pelvis was found to be blood. What is this
condition called?
a. ascites
b. pneumoperitoneum
c. pleural effusion
d. hemoperitoneum
ANNEX 12 Module 2 Knowledge Assessment Test

a. Yolk sac appears after the embryo in a gestational sac.
b. Gestational sac and amniotic sac are same thing.
c. Transvaginal ultrasound is better than transabdominal ultrasound during first trimester.

d. By both trans-vaginal and trans-abdominal ultrasound, embryo is visualized by 7
weeks of gestation.
2. When only yolk sac is seen within the gestational sac, gestational age is
determined by......
a. GSD b. CRL
c. Both d. None
3. In normal conditions, both yolk sac and embryo are seen when the gestational sac
becomes
a. 30 mm in diameter b. 35 mm in diameter
c. 25 mm in diameter d. 20 mm in diameter
4. Dizygotic twins develop when,
a. one ovum is fertilized by two sperm cells during a cycle.
b. two ova are fertilized by one sperm cell each during a cycle.
c. single fertilized ovum splits.
d. twins share a common placenta.
5. CRL is measured when the embryo/fetus is
a. in fully extended position b. in fully flexed position

c. in neutral position d. none of the above
6. While measuring Gestational Sac Diameter(GSD),
a. Internal diameter of sac is measured.
b. external diameter of sac including the covering is measured.
c. inner wall on one side and outer wall on the other side is measured.
d. none of the above are correct.
7. When the gestational sac is not perfectly spherical, gestational age is calculated by
measuring
a. GSD b. CRL
C. AFI d. MSD
8. CRL stands for
a. Crown-Rump Length
b. Cranial-Rump Length
c. Cardiac Rate
d. None of the above
a. M mode is used for measuring Mean sac diameter.
b. B mode is not commonly used in ultrasound.
c. M mode stands for motion mode.
d. When cardiac activity is not visible, M mode is used.
10. Most common presenting symptom of abnormal pregnancy during first trimester is
a. lower abdominal pain b. nausea and vomiting
c. altered appetite d. PV bleeding

11. Ultrasound finding of incomplete abortion is
a. intact gestational sac
b. heteroechoic intrauterine content
c. embryo with no cardiac activity
d. empty uterine cavity
12. Commonest cause of first trimester hemorrhage is
a. abortion b. ectopic pregnancy
c. molar pregnancy d. subchorionnic hemorrhage
13. Early embryonic or fetal demise is called
a. blighted ovum b. threatened abortion
c. tubal ectopic d. missed abortion
14. Commonest site of tubal ectopic pregnancy is
a. interstitium b. fimbrae
c. ampulla d. angular
15. Snowstorm appearance in ultrasound is seen in
a. blighted ovum b. molar pregnancy
c. ectopic pregnancy d. normal finding of first trimester
16. Which of the following statements is correct regarding hydatidiform mole?
a. It is not a benign condition.
b. It has malignant potential.
c. Beta-hCG level is not of any use.
d. Its cause is very well known.
17. Fetal biometry during first trimester includes which of the following?
a. measurement of uterine size.
b. measurement of femur length.
c. measurement of yolk sac diameter.
d. measurement of CRL.
18. In a woman with positive urine pregnancy test, uterus is empty, and fluid is seen
in POD on ultrasound examination. What can be the most likely condition?
a. abortion
b. ectopic pregnancy
c. molar pregnancy
d. none of the above
19. From which of the following conditions, pregnancy can still be continued?
a. ectopic pregnancy
b. missed abortion
c. threatened abortion
d. abortion in progress
20. Implantation occurs after how many days of fertilization?
a. 2-4 days b. 5-6 days
c. 7-10 days d. 12-15 days

Mrs. Kamala, Garvida 1 Para 0, came to your HP for regular check-up today (Magh 03,
2078). Her LMP is of Jestha 30, 2078.
1. Calculate the expected date of delivery (EDD) and weeks of gestation (WOG).
2. Her fundal height corresponds to 36 weeks today (Magh 03, 2078). Does her WOG
and fundal height correspond well? If not, what may be the possible reasons?
3. How will you further proceed in this case?
ANNEX 14 Skill Checklist for Second and Third Trimester
1. Needs Improvement: Step or task not performed correctly, out of sequence (if
necessary), or if omitted
3. Competently performed: step or task performed efficiently and precisely in the proper
sequence (if necessary)
STEPS Performing second and third trimester pregnancy CASES

Getting Ready
1. Prepare the necessary equipments
2. Greet the woman with respect and kindness
3. Ask her name, address, LMP and other required information
(obstetric history)
5. Identify bladder is empty before procedure
6. Tell the woman what is going to be done and encourage her to ask
questions. Listen to her and answer her queries.
7. Procedure (clinical skill)
8. Encourage woman to lie down in supine position on examination
table
9. Keep small towel above symphysis pubis
10. Select and prepare probe properly
11. Uses keyboard and screen functions properly
12. Record client’s identification in USG machine
13. Apply gel and place probe.
14. Head (BPD & HC)
15. Identify fetal head
16. Place the probe in transverse section of head
17. Identify landmarks for the head measurement
18. Measure BPD & HC appropriately
19. Femur Length (FL)
20. Trace the fetal spine
21. Identify femur bone
22. Expose the entire femur length accurately
23. Measure FL appropriately
24. Abdomen (AC)
25. Identify abdomen
26. Place the probe in transverse section
27. Identify proper landmarks for abdomen
28. Measure AC appropriately
29. Fetal Heart Sound (FHS/FHR)
30. Identify FHR and record appropriately
31. Placenta
32. Identify the localization of placenta.
33. Amniotic Fluid Index (AFI)
34. Divide client’s abdomen in four quadrants
35. Measure AFI in all four quadrants accurately
36. Post procedure task
37. Ensure probe cleaned after procedure
Date & signature:

Gravida 5, para 4, 36 years old woman presented to your health post at 34 weeks of
pregnancy. She complaints of vaginal bleeding since morning.
Answer the following questions:
1. What can be the problem with this pregnant woman?
a. Placental abruption
b. Placenta previa
c. Vasa previa
d. all of the above
2. You perform an ultrasound of this pregnant woman and find that the anterior
placenta is located in lower uterine segment and lower placental edge touches the
internal os without covering it. What is the diagnosis?
a. Low Lying Placenta
b. Marginal Placenta Previa
c. Total placenta previa
d. Abruptio placenta with apparent hemorrhage
3. What will be the nature of bleeding in this case?
a. Painless vaginal bleeding
b. bleeding associated with severe abdominal pain and tense abdomen
c. concealed bleeding
4. What will be your next step to manage this case?

a. perform a PV examination to look for signs of labor
b. advise her to come back when labor pain starts and send home
c. Refer her to higher center where caesarean section delivery is possible

d. admit her for normal delivery at your center
5. Which of the following is not a type of placenta previa?
a. low lying placenta

b. complete placenta previa
c. marginal placenta previa
d. posterior upper uterine placenta
ANNEX 16 Knowledge Assessment Test for Module 3

1. Most commonly used formula to calculate expected fetal weight by ultrasound

is
a. Tokyo
b. Rempen
c. Hadlock
d. Watson
2. Fetal head is visualized in close proximity to uterine fundus by ultrasound.

Fetal presentation is?
a. Cephalic b. Breech
c. Transverse d. Oblique
a. In Hadlock2 formula EFW is obtained b. . In Hadlock2 formula EFW is

when BPD, HC and AC are measured obtained when BPD, HC and FL are
measured
c.In Hadlock2 formula EFW is obtained when d. None of the above are correct
BPD, FL and AC are measured
4. Placenta develops from
a. fetal component as decidua basalis

b. maternal component as chorionic frondosum
c.. none of the fetal and maternal components
d. both fetal and maternal components
5. Placenta is completely formed by
a. 10 weeks of gestation b. 12 weeks of gestation
c. 18. weeks of gestation d. by term
6. Function of amniotic fluid is to
a. maintains the temperature of fetus
b. distend the sac in order to allow growth and movement of fetus
c. help in cervical dilatation of cervix during labor
d. All of the above are correct
7. Umbilical cord has
a. two arteries and no vein b. one artery and two veins
c. no artery and one vein d. two arteries and one vein
8. Which of the following structures is not visualized at the transverse section of

head where we measure BPD?
a. Cavum septum pellucidum
b. cerebellum
c. thalamus
d. choroid plexus
a. Maximum Vertical Pool (MVP) is measured in four pockets

b. the width of any pocket to measure AFI must be greater than 1 cm
c. MVP greater than 4 cm is diagnostic of polyhydramnios
d. the sum of depth of amniotic fluid in two quadrants gives amniotic fluid
index (AFI) value
10. For placenta to be labeled as "upper uterine placenta", the lower placental edge
must be
a. more than 2 cm away from internal b. within 2 cm from internal os
Os
c. both a and b are correct. d. both a and b are wrong
11. Habitual abortion presents most commonly during
a. first trimester
b. second trimester
c. third trimester
d. at term
12. Antepartum hemorrhage is defined as bleeding from or into the genital

tract after..........weeks of pregnancy but before the birth of fetus.
a. 28 b. 22
c. 40 d. 35
13. When the lower placental edge touches the either lip of internal os but doesn't
cross it, the condition is called
a. total placental previa b. low lying placenta
c. complete placenta previa d. marginal placenta previa
14. In abruptio placenta of ..................................type, blood is visible outside as per

vaginal bleeding.
a. concealed b. reveled
c. mixed d. none
15. Spalding's sign is evident in
a. placenta previa b. polyhydramnios
c. IUFD d. anencephaly
16. Ultrasound is considered as gold standard for the diagnosis of which of the
following conditions?
a. Fetal anomalies
b. intrauterine fetal death
c. abruptio placenta
17. "Frog eye sign" is seen in which of the following conditions?
a. Intrauterine fetal death
b. Cystic hygroma
c. Ventriculomegaly
d. Anecncephaly
18. Cystic hygroma on ultrasound is mostly encountered during
a. third trimester
b. second trimester
c. first trimester
d. late third trimester
19. An abnormal lateral ventricle size on ultrasound is?
a. more than 5 mm
b. more than 8 mm
c. more than 10 mm

20. At the level of BPD measurement, you see anechoic fluid within fetal head,
loss of brain tissue, midline echogenic falx is intact and BPD is
disproportionately larger as compared to AC and FL. What may be the
abnormality?
a. Hydrocephalus b. exencephaly
c. Cystic hygroma d. none of the above
ANNEX 17 Post Course Knowledge Assessment Questionnaire

1) Endometrium appears ………………… in ultrasound.

a) Isoechoic
b) Hyperechoic
c) Hypoechoic
d) Anechoic
2) Type of transducer used in obstetric ultrasound is
a) Curved(Convex)
b) Linear
c) Sector(Phased array)
d) Endocavitary
3) Which mode of scanning is used for recording of fetal heart rate?
a) B mode
b) D mode
c) M mode
d) N mode
4) Anechoic image in ultrasound is created by
a) Air
b) Fluid
c) Bone
d) Calculus
5) Usual time of visualization of intrauterine gestational sac by transabdominal
ultrasound is..
a) 5 weeks
b) 6 weeks
c) 7 weeks
d) 8 weeks
6) Cardiac activity is noted to
a) confirm pregnancy
b) look for fetal weight
c) Establish the viability of embryo
d) Differentiate between intra and extra-uterine pregnancy
7) Feature of ruptured ectopic pregnancy is/are?
a) Free fluid in abdomen and pelvis
b) Complex mass in adnexa.
c) Empty uterine cavity.
d) All the above
8) Which biometric parameter is used for gestational age estimation in first trimester?
a) BPD
b) CRL
c) AC
d) None of the above
9) Which of the following is the feature of blighted ovum?
a) Gestational sac with MSD of 20 mm with yolk sac.
b) Gestational sac with MSD of 20 mm with embryonic pole.
c) Gestational sac with MSD of 26mm with embryonic pole.
d) Gestational sac with MSD of 26 mm without embryonic pole.
10) Which of the following is the feature of complete molar pregnancy?
a) Presence of fetal cardiac activity.
b) Complex mass with cystic areas within the endometrial cavity.
c) Complex mass with cystic areas within adnexa.
d) Ascites.
11) Which biometric parameter is used for fetal gestational age estimation in 2nd
trimester?
a) CRL
b) MSD
c) GSD
d) AC
12) Detailed congenital anomaly is done in
a) First trimester
b) Early third trimester
c) Second trimester
d) Late third trimester
13) Fetal weight estimation by Hadlock2 utilizes
a) BPD, HC and AC
b) BPD, FL and AC
c) MSD, BPD and AC
d) CRL, HC and AC
14) Which of the following is true regarding cephalic presentation?
a) Transverse lie
b) Fetal head towards fundus
c) Fetal head towards internal Os
d) Fetal breech towards internal Os.
15) Which of the following is true regarding placenta previa?
a) Placenta located at the fundus.
b) Placenta covering the internal os.
c) It is not a cause of antepartum hemorrhage.
d) Vaginal Delivery can be attempted in Complete placenta previa.
16) Which of the following is/are cause/causes of antepartum hemorrhage?
a) Placenta previa
b) Abruptio placenta
c) Vasa previa
d) All of the above.
17) Which of the following is true regarding amniotic fluid index?
a) It is measured in 4 pockets of amniotic cavity.
b) It is measured in single pocket of amniotic cavity.
c) It is measured in 2 pockets of amniotic cavity.
d) It is measured in 3 pockets of amniotic cavity.
18) Which of the following is oligohyraminous?
a) AFI of 3 cm
b) AFI of 27 cm
c) AFI of 8 cm
d) AFI of 20 cm
19) Which of the following is a feature of intrauterine fetal death?
a. Reduced fetal movement
b. Normal cardiac activity
c. Pulsating umbilical cord
d. Overlapping of the calvarial bones
20) Which of the following is a sonological feature of retained product of conception?

a) Free fluid in the pelvis
b) Complex hyperechoic lesion in adnexa
c) Mixed echoic (heteroechoic) content in endometrial cavity
d) Fluid collection in endometrial canal.
ANNEX 18 Checklist for Effective Counseling
Steps /Performance Performance level

1.Receives women warmly
 Introduce yourself
 Greeting voice
 Is empathetic
 Rapport building
2. Appropriate sitting position (L shaped position /90 degree ) is
used
3. Provider demonstrate openness

 Arms open
 Open posture
4. Providers is leaning forward
5. Eye contact is maintained appropriately

6. Provider is relaxed
7. Provider is using effective questioning
8. Provider is paraphrasing the communication periodically
9. Provider is repeating key words

10.Provider is reflecting his/her feeling
11.Provider summarizes the communication
12. Provides appropriate support as appropriate -
 Medical care
 Psychological care
 Information
 Appropriate referral ( need based)
ANNEX 19 Checklist for Breaking Bad News
Steps /Performance Performance level

S= Setting Up and starting
1. Mentally rehearse and arrange for privacy
2. Involves others as well if applicable
3. Make Rapport
P= perception of the women / visitor

4. Determine what the patient/party already know about
the medical condition
I= Invitation
5. Ask the women whether she wishes to know about the
medical condition
K= Knowledge
6. Give medical facts
7. Give information in small pieces
E=Emotions
8. Recognize and empathize the women’s emotions
S= strategy and summary
9. Set up a medical plan of action( treatment /referral)
10. End the meeting
11. Give opportunity to ask questions
ANNEX 20 Log Book
LEARNER'S
LOG BOOK
To be filled up by Participants and signed by trainers
Clinical Experience
Logbook for
ROUSG Training Participants
Participants Name:
Working Health facility:
Training Date:
2. OBSERVATION OR ASSISTANCE AT CASE (AT ALL TRIMESTER)
In this section, the cases which are not recorded in the daily record sheet are written here. It
includes the cases observed and assisted only.
Date Complicated cases observed/assisted Any Comments/Signature

3. DAILY SKILL RECORDING SHEET
The participants will record the details of the case performed daily during the RUSG training period. The trainer will verify and sign at
the bottom of the page after the participant completely performs the following skills independently.
Total number of USG performed:
S. Clients Name Age Address
Presentation
Gestation
Period of
gestational
Placenta
Gravid
No (Yrs)
Date/Sign
LMP
Fetal
EDD
Para
BPD
FHS
AFI
Average
HC
AC
FL
Crown
Rump
S.
No
Clients Name
Age
(Yrs)
Address
Contact
Number
DAILY SKILL RECORDING SHEET
Gravid
Para
LMP
EDD
Period of
Gestation
BPD
HC
AC
FL
Crown
Rump
Presentation
Fetal
FHS
Placenta
AFI
Refer
S.
No
Clients Name
Age
(Yrs)
Address
Contact
Number
Gravid
Para
LMP
EDD
Period of
Gestation
BPD
HC
AC
FL
Crown
Rump
Presentati
Fetal
Weight
FHS
Placenta
AFI
Refer
S.
No
Clients Name
Age
(Yrs)
Address
Contact
Number
Gravid
Para
LMP
EDD
Period of
Gestation
BPD
HC
AC
FL
Crown
Rump
Presentation
Fetal
FHS
Placenta
AFI
Refer
Verified by:
Trainer’s Sign: Date:
VIDEOS OBSERVED TO IDENTIFY THE COMPLICATION NOT
EXPOSED TO CASE (AT ALL TRIMESTER)
In this section, the videos which are observed or discussed to identify complications on which
the partipants are not exposed to real case.
Date Detail of Videos observed Any Comments/Signature

5. RECORD OF COMPLICATED CASES ATTENDED
SN Name of Age Trimester Findings Recording Level of Date/Signature Feedbacks
Mother (WOG) of USG in service competency
scan register
book
Note: The trainer/clinical preceptor will note the level of competency as final assessment; C:
Skills performed competently on client/patient; S: Skills performed with client/patient under
supervision of trainer; N: Needs to practice more to gain competency on skills.
6. SKILL COMPETENCY TRACKING SHEET

Skills Level of Signature and
Competency Date
Intra Uterine Gestation detection
Measurement of Gestational Sac Diameter(GSD)
Crown Rump Length (CRL) Measurement
Cardiac Activity Establishment and Recording
Biparietal Diameter (BPD) measurement
Head Circumference (HC)Measurement
Abdominal Circumference (AC) Measurement
Femur Length (FL) Measurement
Heart Rate (HR) Measurement
Amniotic Fluid Index (AFI) measurement
Placental Localization and Identification of

Lower Edge
Presentation/Lie of fetus
Estimated Fetal Weight
7. COMPLICATED SKILLS TRACKING SHEET

Skills Level of Signature and
Competency Date
Findings in 1st Trimester:
a. Ectopic Pregnancy
b. Molar Pregnancy
c. Missed Abortion/Early Embryonic
Demise
d. Multiple Pregnancy
e. Blighted Ovum/Anembryonic Pregnancy
f. Retained Product of Conception
Findings in 2nd and 3rd Trimester:
Antepartum Hemorrhage
a. Placenta Previa
b. Abruptio Placenta
Presentation
Cephalic
Breech
Transverse
Retained Placenta
8. ROUSG TRAINING EVALUATION
SUBJECTIVE QUESTIONAIRES
(Participants are requested to answer all the questions in their own words.)
1. List out the preparations to be done before scanning?
2. How do you register client’s name in ultrasound machine?
3. How do you improve the image quality of the ultrasound screen?
4. What are the different modes of scanning?
6. How do you identify the presentation of fetus?

7. How do you estimate the average week of gestation by ultrasound?
8. How do you measure the Crown Rump Length (CRL)?
9. How do you measure Head Circumference?
11. How do you measure Biparietal diameter?
12. How do you measure Abdominal Circumference?
13. How do you measure Fetal Heart Rate?

14. How do you measure Femur Length?
15. What is the normal value of Amniotic Fluid Index (AFI) and how do you estimate the
AFI in four quadrants?
16. How do you localize the placental site?
17. How do you measure the distance of placenta from internal os?
18. How do you find the final report after completing the procedure?
19. How can you prepare a monthly report of USG scanning?

20. Do you have ultrasound machine in your place? If yes, who provided? If No, how are
you going to manage ultrasound machine at your health facility?
21. How will you take care of your machine list out?
22. What things do you need to improve to continue the USG services in your health
facility?
23. Do you need any support to start USG scanning service in your place? If yes, list the
support required?
SAMPLE OF RURAL RUSG REPORTING FORM FOR PALIKA
Name of Palika: District:
Month:
Description Ward Number of HF/Mobile Camp
Ward Number
Total Scanned Cases
Ectopic Pregnancy
Multiple Pregnancy
Cardiac activity –ve
“Retained Product of Conception
(RPOC)”
Fetal Death
Hydatidiform Mole (Molar Pregnancy)
Referred Cases
F
i
Total Scanned Cases
Intra-uterine Fetal Death
Second Trimester
Placenta Previa
Abruptio Placenta
Findings/Classification of Scan cases in Number
Fetal Abnormalities
Multiple Pregnancy
Referred Cases
Total Scanned Cases
Presentation-Vertex
Presentation-Breech
Presentation-Transverse
Intra-uterine Fetal Death
Third Trimester
Polyhydraminous
Oligohydraminous
Placenta Previa
Abruptio Placenta
Fetal Abnormalities
Multiple Pregnancy
Referred Cases
Other Complication
Total Scanned Cases
Total New Cases
Total Repeated Cases
Total referred Cases
Details of Refer Cases Refer Refer Refer Refer Refer
Case 1 Case 2 Case 3 Case 4 Case 5
Refer Cases
Referred to
Cause of Refer
Outcome of Refer case
Prepared by: Verified by:
Name: Name:
Designation: Designation:
Date: Date:
u|fld0fcN6«f;fp08 sfo{qmdsf] k|ltj]bg x/]s kflnsfdf /x]sf] u|fld0f cN6«f;fp08
sfo{qmd ;]jf /lhi6/ af6 6\ofnL l;6df ptf/L tof/ ug'{kb{5 . 3'lDt lzlj/af6 lbOPsf] u|
fld0f cN6«f;fp08 ;]jfsf] clen]v u|fld0f cN6«f;fp08 ;]jf /lhi6/df cWojflws x'g] x'gfn]
3'lDt lzlj/af6 lbOPsf] ;]jf o; k|ltj]bgdf hf]8g' kb{}g . t/ u|fld0f cN6|f;fp08 ;]jf pQm
kflnsf aflx/af6 klg ;]jfu|fxL x'g'x'G5 eg] pQm ;]jfsf] k|ltj]bg aflx/sf] pNn]v ul/ k|
ltj]bg ug'{ kb{5 .
Name of Palika of] dxndf kflnsfsf] gfd n]Vg' kb{5 .

District of] dxndf lhNnfsf] gfd n]Vg' kb{5 .
Month of] dxndf h'g dlxgfsf] k|ltj]bg agfPsf] xf] To;sf] dlxgf / ;fn n]Vg'
kb{5 .
Ward No of] dxndf kflnsfsf] j8f g+ n]Vg' kb{5 . :jf:Yo ;+:yfdf ;]jf lnPsf]
xsdf ;]jf/lhi6/df S.N. x]/L (HF) n]Vg] / 3'lDt lzlj/af6 ;]jf lnPsf]
xsdf eg] ;]jf /lhi6/sf] ldltdf x]/L sf]i7df /x]sf] MC x]/L (MC) k|
ltj]bg tof/ ug'{kb{5 . olb Pp6} j8fdf :jf:Yo ;+:yf / 3'lDt lzlj/ b'a}
jf6 ;]jf lbPsf] 5 eg] To;sf] nflu Pp6} kfgfsf] 5'6f5'§} dxndf ljj/0f
n]Vg' kb{5 .
o; dxndf q}dfl;s cg';f/ /indicator cg';f/ cN6«f;fp08 u/]s]f hDdf ;+Vof n]Vg' kb{5 .
Total scan cases of] dxndf ue{jtL ePsf] klxnf] q}dfl;sdf u|fld0f
Findings/Classification of Scanned Cases
cN6«f;fp08 ;]jf lng cfPsf dlxnx?sf] hDdf ;

+Vof n]Vg' kb{5 .
Ectopic pregnancy of] dxndf klxnf] q}dfl;sdf ;]jf lng cfPsf ue{jtL
dlxnf h;sf]Ectopic pregnancy eg]/ z+sf u/]sf]
hDdf ;+Vof n]Vg' kb{5 .
Multiple pregnancy of] dxndf klxnf] q}dfl;sdf ;]jf lng cfPsf
dlxnfx?sf] ue{df ! eGbf j9L e|"0f ePsf] hDdf
dlxnfsf] ;+Vof n]Vg' kb{5 .
First Trimester
Cardiac activity -ve klxnf] q}dfl;sdf ;]jf lng cfPsf] ue{jtL dlxnfsf]
e|"0fsf] d'6'sf] 38\sg ge]l6Psf] hDdf ;+Vof of]
dxndf n]Vg' kb{5 .
Retained product of of] dxndf klxnf] q}dfl;sdf ue{ktg eP/ ;]jf lng
conception (abortion)
cfPsf] dlxnfsf] hDdf ;+Vof n]Vg' kb{5 .
Fetal death of] dxndf klxnf] q}dfl;sdf ;]jf lng cfPsf ue{jtL
dlxnfsf]fetal movement jffetal heart beat
gePsf] dlxnfsf] hDdf ;+Vof n]Vg' kb{5 .
Hydatidiform (Molar of] dxndf klxnf] q}dfl;sdf ;]jf lng cfPsf ue{jtL
Pregnancy)
dlxnfsf] e|"0fsf] ;fdfGo geO{Hydatidiform
mole ePsf] dlxnfsf] hDdf ;+Vof n]Vg' kb{5 .
Referred of] dxndf klxnf] q}dfl;sdf ;]jf lng cfPsf k|]if0f
u/]sf] dlxnfsf] hDdf ;+Vof n]Vg' kb{5 .
Total scanned cases of] dxndf bf]>f] q}dfl;sdf lbPsf] hDdf
cN6«f;fp08 ;]jfsf] ;+Vof n]Vg' kb{5 .
Intra-uterine fetal death of] dxndf bf]>f] q}dfl;sdf ;]jf lng cfPsf Intra-
uterine fetal death elg kQf nufPsf] hDdf
Hydatidiform (Molar of] dxndf bf]>f] q}dfl;sdf ;]jf lng cfPsf ue{jtL
Pregnancy)
dlxnfsf] e|"0f ;fdfGo geO{Hydatidiform mole
ePsf] hDdf dlxnfsf] ;+Vof n]Vg' kb{5 .
Placenta Previa of] dxndf bf]>f] q}dfl;sdf ;]jf lng cfPsf /
Placenta previa elg kQf nufPsf] hDdf
Abruptio placenta of] dxndf bf]>f] q}dfl;sdf ;]jf lng
cfPsf /Abruptio placenta elg kQf nufPsf] hDdf
Fetal anomalies of] dxndf bf]>f] q}dfl;sdf ;]jf lng cfPsfFetal
anomalies elg kQf nufPsf] hDdf dlxnfsf] ;
+Vof n]Vg' kb{5 .
Second Trimester
Multiple pregnancy of] dxndf bf]>f] q}dfl;sdf ;]jf lng cfPsf

dlxnfx? dWo ue{df ! eGbf j9L e|"0f ePsf
dlxnfx?sf] hDdf ;+Vof n]Vg' kb{5 .
Referred of] dxndf bf]>f] q}dfl;sdf ;]jf lng cfPsf k|]if0f
Total scanned cases of] dxndf t]>f] q}dfl;sdf ;]jf lng cfPsf hDdf
cN6«f;fp08sf] ;+Vof n]Vg' kb{5 .
Third Trimester
Presentation-Vertex of] dxndf t]>f] q}dfl;sdf ;]jf lng cfPsf e"|

0fsf]Vertex Presentation kQf nu]sf] hDdf
Presentation-Breech of] dxndf t]>f] q}dfl;sdf ;]jf lng cfPsf e"|
0fsf]Breech Presentation kQf nu]sf] hDdf
Presentation-Transverse of] dxndf t]>f] q}dfl;sdf ;]jf lng cfPsf e"|
0fsf]Transverse Presentation kQf nfu]sf] hDdf
Intra-uterine fetal death of] dxndf t]>f] q}dfl;sdf ;]jf lng cfPsfIntra-
uterine fetal death elg kQf nufPsf] hDdf
Polyhydraminous of] dxndf t]>f] q}dfl;sdf ;]jf lng
cfPsf /Polyhydraminous elg kQf nufPsf] hDdf
Oligohydraminous of] dxndf t]>f] q}dfl;sdf ;]jf lng
cfPsf /Oligohydraminous elg kQf nufPsf]
hDdf dlxnfsf] ;+Vof n]Vg' kb{5 .
Hydatidiform (Molar of] dxndf t]>f] q}dfl;sdf ;]jf lng cfPsf ue{jtL
Pregnancy)
dlxnfsf] e|"0f ;fdfGo geO{Hydatidiform mole
ePsf] hDdf dlxnfsf] ;+Vof n]Vg' kb{5 .
Placenta Previa of] dxndf t]>f] q}dfl;sdf ;]jf lng
cfPsf /Placenta previa elg kQf nufPsf] hDdf
Abruptio placenta of] dxndf t]>f] q}dfl;sdf ;]jf lng cfPsf /
Abruption placenta elg kQf nufPsf] hDdf
Fetal anomalies of] dxndf t]>f] q}dfl;sdf ;]jf lng cfPsfFetal
anomalies elg kQf nufPsf] hDdf dlxnfsf] ;
+Vof n]Vg' kb{5 .
Multiple pregnancy of] dxndf t]>f] q}dfl;sdf ;]jf lng cfPsf dlxnfx?
dWo ue{df ! eGbf j9L e|"0f ePsf dlxnfx?sf]
hDdf ;+Vof n]Vg' kb{5 .
Refer of] dxndf t]>f] q}dfl;sdf ;]jf lng cfPsf k|]if0f
Other Complication dfly pNn]lvtcomplication afx]s cGo hl6ntf
kQf nfu]df o; dxndf ;Dk"0f{ ljj/0f eg{‘ kb{5 .
Total Scanned Cases of] dxndf k|ltj]bg agfpg] dlxgfdf ul/Psf] u|fld0f
cN6«f;fp08sf] hDdf ;+Vof of] dxndf n]Vg'
kb{5 .
Total New Cases of] dxndf k|ltj]bg agfpg] dlxgfdf klxnf] k6s u|
fld0f cN6«f;fp08 ug{ cfPsf dlxnfx?sf] hDdf ;
+Vof n]Vg' kb{5 .
Total Repeated Cases of] dxndf k|ltj]bg agfpg] dlxgfdf bf]xf]¥of/ ;]jf
lng cfPsf ue{jtL dlxnfx?sf] hDdf ;+Vof n]Vg'
kb{5 .
Total Referred Cases of] dxndf k|ltj]bg agfpg] dlxgfdf k|]if0f ePsf
lj/fdLx?sf] hDdf ;+Vof n]Vg' kb{5 .
Referred to of] dxndf s'g} klg rf}dfl;sdf cN6«f;fp08 ;]jf
lnPkl5 k|]if0f u/]sf] la/fdL k7fPsf] :jf:Yo ;
+:yfsf] gfd n]Vg' kb{5 . k|ltj]bg agfpg] dlxgfdf
! gDa/df k|]if0f u/]sf] la/fdLsf] ljj/0fcase !, @
gDa/df k|]if0f u/]sf] la/fdLsf] ljj/0fcase @ ub}
{ n]Vb} hfg' kb{5 .
Cause of refer of] dxndf s'g} klg rf}dfl;sdf cN6«f;fp08 ;]jf
lnPkl5 k|]if0f ug'{sf] sf/0f n]Vg' kb{5 . k|ltj]bg
agfpg] dlxgfdf ! gDa/df k|]if0f u/]sf] la/fdLsf]
k|]if0f ug'{kg]{ sf/0fcase !, @ gDa/df k|]if0f
u/]sf] la/fdLsf] ljj/0f case @ ub}{ n]Vb} hfg'
kb{5 .
Outcome of refer case of] dxndf s'g} klg rf}dfl;sdf cN6«f;fp08 ;]jf
lnPkl5 k|]if0f u/]sf] dlxnf / e|"0fsf] cj:yf s] eof]
n]Vg' kb{5 . k|ltj]bg agfpg] dlxgfdf ! gDa/df
Refer Cases
k|]if0f u/]sf] la/fdLsf] cj:yfcase !, @ gDa/df

k|]if0f u/]sf] la/fdLsf] cj:yfcase @ ub}{ n]Vb}
hfg' kb{5 .
9.2 SAMPLE OPEN TALLY SHEET
HMIS 1.6 :v'Nnf ;dfof]hg kmf/d(Open Tally Sheet)
kl/ro M
:jf:Yo ;+:yfaf6 lbOPsf] ;]jfx?sf] ljj/0f ;dfof]hg ug{ -Psd'i7 lgsfNg_ o; kmf/dsf] k|
of]u ul/G5 .
cfjZostf M
laleGg /lhi6f/, sf8{ kmf/fdx?df 5l/P/ /x]sf clen]vx?nfO{ ;/n tyf Aojl:yt
tl/sfn] ;dfof]hg u/L k|ltj]bg tof/ kfg{ o; kmf/fdsf] cfjZsotf k/]sf] xf] .
v'Nnf ;dfof]hg kmf/fd
l;=g+ ;"rs÷sfo{q
md
eg]{ tl/sf :
v'Nnf ;dfof]hg kmf/fdsf] afofF lt/ :jf:Yo ;+:yf lSnlgssf] gfd / bfofF lt/ ;~rflnt
sfo{qmdx? n]Vg' kb{5 . ;dfof]hg ubf{ h'g ;]jfx? ;dfof]hg ug{ nfu]sf] xf] qmd ;+Vof
/gfd bfofF lt/ ;dfof]hg ug{ nfluPsf] ;]jfsf] gfd n]lv ;f] d'lg lbOPsf] ;]jf ;+Vof c+sdf
jf -I_w;f]{ tflg hgfpg' kb{5 .
9.3 SAMPLE RUSG SERVICE REGISTER FOR HEALTH FACILITY
kl/ro M
u|fld0f cN6«f;fp08 ;]jf lng cfPsf k|To]s dlxnfnfO{ u|fld0f cN6«f;fp08 /lhi6/df btf{ ul/G5 . ue{jtL cj:yfdf
cN6«f;fp08 ;]jf lnPsf] ljj/0f, o; cj:yfdf cfdf / jRrfdf b]lvPsf] hl6ntf / ;f] sf] Joj:yfkgsf] nflu k|]if0f ul/Psf] ljj/0f o;df
/flvG5 . :jf:Yo ;+:yf / 3'lDt ;]jf b'j} :yfgaf6 k|bfg u/]sf] cN6«f;fp08 ;DjGwL ;a} ;]jfsf] clen]v of] /lhi6/df /flvG5 . of]
/lhi6«/sf] x/]s k[i7df b'O{ hgf dlxnfnfO{ lbPsf] ;]jfsf] dfq /]s8{ ug{ ;lsG5 . o;} /lhi6/ af6 u|fld0f cN6«f;fp08
sfo{qmdsf] k|ltj]bg tof/ u/L ;f] sf] cfwf/df sfo{qmd ;Fu ;DjlGwt ;"rsx?sf] ljZn]if0f ul/G5 .
u|fld0f cN6«f;fp08 ;]jfsf] ljj/0f kflnsf cg';f/ ug'{ kg]{ ePsf]n] k|To]s j8fsf] nflu Pp6} /lhi6/sf] 5'§f5'§} kfgf k|of]u
ug'{ kb{5 . :jf:YosdL{n] sfo{If]qsf uf=kf÷g=kf sf] cg'dflgt ue{jtLnfO{ cfwf/ dfgL j8fsf] nflu /lhi6/sf] kfgf 5'6\ofpg'
kb{5 . sfo{ If]q eGbf aflx/sf ;]jfu|fxLsf] nflu o; /lhi6/sf] clGtd kfgfx? 5'6\ofpg' kb{5 . ;DalGwt ;+:yf jf j8fsf] sfo{ If]q
eGbf jflx/sf ;]jf u|fxLx?sf] ;+Vof clws x'g] :jf:Yo ;+:yfn] cGo uf=kf÷g=kf= sf ;]jfu|fxLx?sf] nflu dfq 5'§} /lhi6/ klg k|
of]u ug{ ;lsg]5 .
3'lDt lzlj/ ;]jfjf6 k|bfg ul/Psf] u|fld0f cN6«f;fp08 ;]jfsf] ljj/0f 3'lDt lzlj/ ;+rfng :yndf g} nu]/ ljj/0f
eg]{ ug'{ kb{5 . dlxnfn] uef{j:yfdf lnPsf] ;Dk"0f{ u|fld0f cN6«f;fp08sf] s'n ;+Vof olsg ug{sf nflu ;f]
dlxnfn] cGo ;+:yfjf6 k|fKt u/]sf cN6«f;fp08 ;]jfsf] ljj/0f cN6«f;fp08 ;]jfsf] lglZrt u/]/ clgjfo{ ?kdf
o; /lhi6/df cWofjlws ug'{ kb{5 . ;]jf k|bfosn] o;} /lhi6/af6 dfl;s k|ltj]bg tof/ ug'{kb{5 .
S. Basic First Trimester Status
N. Information
Pregnancy Information
Name of Women and
Other Complications
Outcome of referred
Second Trimester
Third Trimester
Referred to…..
Cause of refer
Other Visit 1
Other Visit 2
Other Visit 3
Referred
patients
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
MRP No. Scanned DD/MM/ Scanned Date DD/ DD/ DD/ DD/ DD/
date YYYY MM/ MM/ MM/ MM/ MM/
YYYY YYYY YYYY YYY YYY
Y Y
Period of Gestation Period of Gestation

SR No. Ectopic Yes 1 Bi-Parietal Diameter
Pregnancy
No 2 Head Circumference
Abdomen Circumference
Caste Code Number of gestational Femur Length
sac
Vertex 1 1 1 1
Cardiac +ve
activity
Breech 2 2 2 2
Presentation
Age -ve Transverse 3 3 3 3
Lie
Crown Rump Length
Contact No Gravid Retained Product of Fetal Heart Sound

a Conception (RPOC)
Fetal Weight
Palika Name Para Fetus Live Fetus Live 1 1 1 1 1
Dead Dead 2 2 2 2 2
Ward No LMP Location of Placenta Length of Cervix
DD/ Retained Product of Conception 1 1 1

MM/
YY
Village/Tole EDD Hydatidiform 1 Location of Placenta
(Molar
Pregnancy)
DD/ Refer 1 Polyhydraminous 1 1 1 1
MM/
YYYY
Referred Oligohydraminous 1 1 1 1
to………………
Cause of refer Hydatidiform (Molar Pregnancy) 1 1 1 1 1
Placenta Previa 1 1 1 1 1
Outcome of Referred Abruptio Placenta 1 1 1 1 1
Patients
Fetal abnormalities
Number of fetus
MRP No. Scanned DD/MM/ Scanned Date DD/ DD/ DD/ DD/ DD/
date YYYY MM/ MM/ MM/ MM MM/
YYYY YYYY YYY / YYY
Y YY Y
YY
Period of Gestation Period of Gestation

SR No. Ectopic Yes 1 Bi-Parietal Diameter
Pregnancy
No 2 Head Circumference
Abdomen Circumference
Caste Code Number of gestational Femur Length

sac
Vertex 1 1 1 1
Cardiac +ve
activity
Breech 2 2 2 2
Presentation
-ve
Age Transverse 3 3 3 3
Lie
Crown Rump Length
Contact No Gravi Retained Product of Fetal Heart Sound

da Conception (RPOC)
Fetal Weight
Palika Name Para Fetus Live Fetus Live 1 1 1 1 1
Dead Dead 2 2 2 2 2
Ward No LMP Location of Placenta Length of Cervix
DD/ Retained Product of Conception 1 1 1

MM/
YY
Village/Tole EDD Hydatidifor 1 Location of Placenta

m (Molar
Pregnancy)
DD/ Refer 1 Polyhydraminous 1 1 1 1

MM/
YYY
Y
Referred Oligohydraminous 1 1 1 1
to………………
Cause of refer Hydatidiform (Molar Pregnancy) 1 1 1 1 1
Placenta Previa 1 1 1 1 1
Outcome of Abruptio Placenta 1 1 1 1 1

Referred Patients
Fetal abnormalities
Number of fetus
dxn g+ dxn lzif{s lgb]{zg

! qm=;+=(S.N) o; ;]jf lng cfPsf ;]jfu|fxLx?sf] qmd ;+Vof k|To]s dlxgf ! af6 z'?jft ub{} hfg'kb{5 . csf]
{ dlxgfdf k'g M qm=; ! jf6 z'? ug'{ kb{5 .
@ ;fdfGo hfgsf/L
d"n btf{ g+(MR d"n btf{ /lhi6/df btf{ x'bfsf] gDa/ dft[ :jf:Yo sf8{jf6 o; dxndf r9fpg' kb{5 .
No)
;]jf btf{ g+ (SR. Pp6f dlxnfnfO{ Ps k6ssf] uef{:yfdf Pp6f dfq btf{ gDj/ lbO{ btf{ ug'{ kb{5 . ;f]xL
No) dlxnf ;f]xL k6ssf] ue{df bf]xf]¥ofP/ u|fld0f cN6«f;fp08 ;]jf lng cfpFbf klxn] btf{u/]s]f nx/df
;DjlGwt ;]jf lnPsf] ljj/0f pNn]v ug'{ kb{5 . cyf{t ;doj4 ?kn] qmlds ;]jf ljj/0f v'Ng] u/L
ljj/0f /fVg' kb{5 . ;]jf btf{ g+=k|To]s cf=j= sf] >fj0f b]lv k'gM ! b]lv z'? ul/G5 . u|fld0f cN6\
f;fp08sf] ;]jf btf{ g+= dft[ :jf:Yo sf8{sf] cufl8sf] efudf marker n] n]Vg] ug'{kb{5 . 3'lDt
lzlj/af6 ;]jf lnPsf] dlxnfsf] xsdf 3'lDt lzlj/af6 ;]jf lnPsf] ldltsf] k5fl8MC n]lvlbg] / k|To]s
dlxgfsf] l/kf]6{ agfpbf MC af6 ;]jf lnPsf] dlxnfx?sf] 5'§} l/kf]{l6ª ug]{ . l/kf]{l6ª ubf{ l/kf]
{l6ª kmf/fdsf] j8f n]Vg] dxndf j8f gDa/ n]lv sf]i7 leqMC n]Vg' kb{5 . olb Ps} j8fdf 3'lDt ;]jf
lzlj/ / :jf:Yo ;+:yf b'j} :yfgaf6 ;]jf k|bfg u/]sf] 5 eg] 5'§f5'§} dxndf l/kf]l6ªug'{ kb{5 .
ue{jtLsf] hft o; ;]jf lng cfPsf dlxnfx?sf] hft÷hftL ;d"x cg';f/sf] sf]8 gDa/ o; dxndf n]Vg' kb{5 . -
hftL sf]8 h:t} )!, )@, ========================)^_ ;]jfu|fxLsf] pd]/ / ;Dks{ gDj/ o;}
pd]/ / ;Dks{ g+= dxnsf] ;DjlGwt sf]7fdf n]Vg' kb{5 .
7]ufgf ;DjlGwt ;]jfu|fxLsf] ufpF÷6f]n÷uf=kf÷g=kf :ki6 ;Fu v'Ng] u/L n]Vg' kb{5 . :jf:Yo ;+:yfsf]
uf=kf÷g=kf÷ufp sfo{If]q eGbf aflx/sf] ;]jfu|fxLsf] xsdf o; dxndf lhNnf uf=kf÷g=kf= ;d]tv'Ng] u/L n]Vg'
F÷6f]n÷j8f g+= kb{5 .
# ue{jtLsf] gfd y/
ue{ ljj/0f
ue{jtLsf] gfd y/ o; ;]jf lng cfPsf] dlxnfsf] gfd / y/ o; dxndf 7f8f] kf/L n]Vg' kb{5 .
Gravida o; ;]jf lng cfPsf dlxnfsf] hDdf ue{ -xfnsf] ;d]t_ Gravida sf] dxndf pNn]v ug'{kb{5 .
Para o; ;]jf lng] dlxnfn] xfn;Dd hGdfPsf] hDdf hGd ;+VofParity sf] dxndf pNn]v ug'{ kb{5 .
Parity sf] u0fgf ubf{ ue{jtL ePsf] @# xKtf eGbf kl5 hGd ePsf] ;a} ue{sf] u0fgf ug'{kb{5 .
olb xfnsf] ue{ klxnf] ue{ xf] jf o; eGbf klxn] pQm dlxnfaf6 s'g} hGd ePsf] 5}g eg]Parity sf]
dxndf z"Go n]Vg' kb{5 .
cflv/ /h:jnf ePsf] o; ;]jf lng cfPsL dlxnfsf] clGtd k6s /h:jnf ePsf] ldlt (LMP) ut], dlxgf / ;fn n]Vg' kb{5 .
klxnf] lbgsf] ldlt
(LMP)
DD/MM/YYYY
k|;j cg'dflgt LMP sf] cfwf/df lghsf] k|;j cg'dflgt ldlt(EDD) kQf nufO{ ut], dlxgf / ;fn n]Vg' kb{5 .
ldlt(EDD)
DD/MM/YYYY
$ klxnf] q}dfl;s
klxnf] olb dlxnf klxnf] q}dfl;s(0 to 14 WKS) leqsf] 5 eg] of] dxndf ut], dlxgf / ;fn n]Vg' kb{5 .
q}dfl;s(First
Trimester)
Scan date o; dxndf cN6«f;fp08 u/]sf] ldlt ut], dlxgf / ;fn n]Vg' kb{5
Period of gestation o; dxndf slt xKtfsf] ue{jtL xf] ;f] n]Vg' kb{5 .
Ectopic pregnancy of] dxndf olbEctopic pregnancy eg]/ z+sf nfu]df ! df / z+sf gnfu]df @ df uf]nf] -)_ lrGx
nufpg' kb{5 .
Number of gestational cN6«f;fp08 ubf{ slt j6fgestational Sac b]vf k5{ Tof] ;+Vof of] dxndf n]Vg' kb{5 .
Sac
Cardiac activity of] dxndf jRrfsf] d'6'sf] w8\sg b]Vg jf;'Gg ;Sof] eg] +ve / 5}g eg] -ve df uf]nf] nufpg' kb{5 .
Crown Rump of] dxndf fetus sf] head to toe (Maximal Straight line of embryo) sf] Length Measurement
Length u/]/ cfPsf] nDjfO{ n]Vg' kb{5 .
Retained Product of] dxndf olb abortion ePsf] xf] eg] missed abortion or Blighted ovum, Incomplete abortion,
of Conception complete abortion h] xf] ToxL n]Vg' kb{5 .
(RPOC)
Fetus of] dxndf olb Fetus live 5 eg] ! / dead 5 eg] @ df uf]nf] lrGx nufpg' kb{5 .
Location of of] dxndf Placenta Anterior or Posterior s] 5 ;f] cg';f/ n]Vg' kb{5 .
Placenta
Hydatidiform of] dxndf olb hydatidiform mole 5 eg] ! df uf]nf] nufpg] geP s]xL gug]{ .
(Molar Pregnancy)
Refer of] dxndf cN6«f;fp08 u/]kl5 k|]if0f ug'{eof] eg] ! df uf]nf] nufpg' kb{5 .
Referred of] dxndf lj/fdL k|]if0f u/]s]f :jf:Yo ;+:yfsf] gfd n]Vg' kb{5 .
to ....................
Cause of Refer of] dxndf k|]if0f ug'{sf] sf/0f n]Vg' kb{5 .
Outcome of of] dxndf k|]if0f u/]/ pkrf/ u/] kl5 la/fdLsf] cj:yf s:tf] eof] pNNf]v ug'{ kb{5 .
referred patients
% cj:yf (status) of] dxndf pNn]v ul/Psf] ljleGg ljj/0f cg';f/
olb Second trimester (14 Wks to 28 Wks) sf] 5 eg] Second trimester sf] dxn gDa/ ^ df ljj/0f
eg'{ kb{5 .
olb ue{jtL dlxnf third trimester (28 Wks to 42 Wks) sf] 5 eg] third trimester sf] dxn gDa/ &
df ljj/0f eg'{ kb{5 .
oL dxnx?df klg Frist trimester sf] dxndf h:t} ul/ ljj/0f eg'{kb{5 .
Scanned date cN6«f;fp08 u/]sf] ldlt lbg, dlxgf / ;fndf n]Vg'kb{5 .
Period of gestation slt xKtfsf] ue{jtL xf] ;f] n]Vg'kb{5 .
Bi-Parietal e|"0fsf] 6fpsf]sf] uf]nfO{ (bi-parietal diameter - Measure outer table of the skull to inner
Diameter table) dfkg ubf{ cfPsf] k|ltkmn n]Vg'kb{5 .
Head e|"0fsf] 6fpsf]sf]] uf]nfO{ (HC-Measure around the outer table of the skull) dfkg ubf{ cfPsf]
Circumference k|ltkmn n]Vg'kb{5 .
Abdomen e|"0fsf] k]6sf] uf]nfO{ dfkg ubf{ cfPsf] k|ltkmn n]Vg'kb{5 .
Circumference
Femur Length e|"0fsf] Femur Length sf] dfkg ubf{ cfPsf] k|ltkmn n]Vg'kb{5 .
Presentation e|"0fsf] z/L/sf] efusf] ;DjGw internal Os ;Fu kQf nufP cg';f/ Vetex eP !, breech eP @ /
transverse lie eP # df uf]nf] lrGx nufpg] t/ bf];|f] q}dfl;sdf of] ljj/0f n]Vg'kb{}g .
Fetal Heart Sound e|"0fsf] d'6'sf] 38\sg dfkg u/L cfPsf] k|ltkmn n]Vg'kb{5 .
Fetal Weight BPD, HC, AC, FL dfkg ubf{ ultrasound machine sf] screen df cfPsf] k|ltkmn (fetal weight)
o; dxndf n]Vg'kb{5 .
Fetus e"0f live 5 eg] ! / dead 5 eg] @ df uf]nf] nufpg'kb{5 .
Length of Cervix Internal OS b]lv External Os ;Ddsf] nDjfO{ dfkg u/]/ cfPsf] k|ltkmn o; dxndf n]Vg' kb{5 .
ljz]if u/L bf];|f] q}dfl;sdf of] dxndf ljj/0f eg'{ cToGt h?/L 5 .
Retained product of olb ue{jtL dlxnfsf] jRrf v]/ uPsf] xf] eg] cj:yf x]/L kQf nufPsf] k|ltkmn o; dxndf n]Vg'
conception
kb{5 .
Location of Placenta of] dxndfPlacenta Anterior or Posteriors] 5 ;f] cg';f/ n]Vg' kb{5 .
Polyhydraminous Amniotic fluid index dfkg ubf{ olb k|ltkmn @)CM eGbf dfly ePdf of] dxnsf] ! df uf]nf]
nufpg' kb{5 .
Oligohydraminous Amniotic fluid index dfkg ubf{ olb k|ltkmn & b]lv * CM eGbf sd cfPdf jmhf of] dxnsf] ! df
uf]nf] nufpg' kb{5 . ljz]if u/L bf];|f] q}dfl;s / t];|f] q}dfl;sdf AFI dfkg ug'{ cTofjZos 5 .
Hydatidiform (Molar of] dxndf olbhydatidiform mole 5 eg] ! df uf]nf] nufpg] geP s]xL gug]{ .
Pregnancy)
Placenta Previa olbplacenta internal OS sf] 5]pdf jf internal OS dfly 5 eg] of] dxnsf] ! df uf]nf] nufpg' kb{5 .
Abruptio Placenta olbAbruptio Placenta kQf nfu]df of] dxnsf] ! df uf]nf] nufpg' kb{5 .
Fetus abnormalities of] dxndfFetal anomalies e]6]dfscanning sf] k|ltkmn o;df n]Vg' kb{5 h:t}Anencephaly/
Cystic Hygroma / Ventriculumeghaly / Hydrocephalus
Number of fetus of] dxndf cN6«f;fp08 ubf{ kQf nfu]sf] e|"0fsf] ;+Vof n]Vg' kb{5 .
* Other visit 1 o; dxndf olb ue{jtL dlxnfn] klxnf] q}dfl;sdf ! k6s eGbf a9L ;]jf lnPsf] /x]5 eg] other visit 1
sf] dxndf ljj/0f eg'{ kb{5 .
( Other visit 2 o; dxndf olb ue{jtL dlxnfn] bf];|f] q}dfl;sdf ! k6s eGbf a9L ;]jf lnPsf] /x]5 eg] other visit
2sf] dxndf ljj/0f eg'{ kb{5 .
!) Other visit 3 o; dxndf olb ue{jtL dlxnfn] t];|f] q}dfl;sdf ! k6s eGbf a9L ;]jf lnPsf] /x]5 eg] other visit 3 sf]
dxndf ljj/0f eg'{ kb{5 .
!! Other dfly pNn]lvt complication afx]s cGo hl6ntf kQf nfu]df o; dxndf ;Dk"0f{ ljj/0f eg'{ kb{5 .
Complications
!@ Refer of] dxndf bf]>f] / t]>f] q}dfl;sdf cN6«f;fp08 u/]kl5 k|]if0f ug'{eof] eg] ! df uf]nf] nufpg]
!# Referred to of] dxndf bf]>f] / t]>f] q}dfl;sdf cN6«f;fp08 u/]kl5 lj/fdL k|]if0f u/]s]f :jf:Yo ;+:yfsf] gfd
n]Vg' kb{5 .
!$ Cause of refer of] dxndf bf]>f] / t]>f] q}dfl;sdf cN6«f;fp08 u/]kl5 k|]if0f ug'{sf] sf/0f n]Vg' kb{5 .
!% Outcome of dxndf bf]>f] / t]>f] q}dfl;sdf cN6«f;fp08 u/]kl5 k|]if0f u/]/ pkrf/ u/] kl5 la/fdLsf] cj:yf s:tf]
referred cases eof] pNNf]v ug'{
9.4 RUSG TRAINING
ACTION PLAN FORM
YEAR:
District:
Name of Participant: Name of HF:
Date:
S.No Activities Sub-Activities Responsible By when (Date) Support Needed How to know
Person achievement

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Rural Obstetric Ultrasound

Training For Nurses

Barriers of effective communication in healthcare..................................................................................10

Breaking Bad News.................................................................................................................................15

2. describe general structure and parts of a portable ultrasound unit

3. identify and operate obstetric knobology (Functions of obstetric keys )

4. care portable ultrasound unit and its parts

5. identify and manage common troubles

6. apply basic transabdominal obstetric scanning techniques

7. identify normal female pelvic structures (bladder, uterus and adnexa)

8. identify and localize gestational sac

9. identify Cardiac activity

10. use M- Mode scanning to record fetal heart rate

11. identify fetal head, fundus of uterus and Internal Os

12. interpret fetal presentation

13. measure CRL /GSD,BPD,HC,AC and FL

14. identify normal placenta and lower placental edge

15. carry out simple amniotic fluid survey

16. calculate and interpret amniotic fluid index

17. provide effective counseling for timely and appropriate referral

18. document the records and report to the concern facilities

Learner selection criteria

Remember - Communication is not just saying something

Barriers of effective communication in healthcare

Techniques of effective communication

Basic Skills of counseling-

P – PERCEPTION: Assess the patient’s understanding of the seriousness of their condition.

I – INVITATION: Get permission to have the discussion.

K – KNOWLEDGE: Explain the facts.

E – EMOTIONS: Be Empathic, Be supportive.

Words are like loaded pistols

Basics of ultrasound unit (SESSION 2)

Skill practice (SESSION 3)

15 mins  Summary of the day

45 mins Lunch Break

3 hours Basics of Obstetric imaging (SESSION 5)

Skills practice Session (SESSION 6)

15 mins  Summary of the day

Skill Practice Session(Practice in simulation) (SESSION 8)

45 mins Lunch Break

 Identification of Cardiac activity

45 mins Lunch Break

3 hours Skills Practice Session (SESSION 15)

15 mins Summary of the day

45 mins Lunch Break

3 hours Skill Practice Session (SESSION 17)

15 mins Summary of the day

Placental localization (SESSION 18)

3 hours Skill Practice Session (SESSION 19)

15 mins Summary of the day

180 mins Day 8

 Documentation( recording and reporting) and service readiness

45mins Lunch Break

15 mins Summary of the day

Mark the following statements as True (T) or false (F).

Q.N. Statements Mark

1. First trimester pregnancy is regarded upto 20 weeks of 1.

2. Gestational sac and yolk sac are different structures. 2.

3. Implantation occurring outside the uterine cavity is 3.

Learners' Guide Final Arrangement. Rajiv and Punam (00000002)

Learners' Guide Final Arrangement. Rajiv and Punam (00000002)

Learners' Guide Final Arrangement. Rajiv and Punam (00000002)