Hi Brittany,

This posting is AMAZING!! Part of me wants to print this out and add to my clinical binder as a cheat sheet, is that weird lol? This has been one of my biggest struggles is getting fetal lie down! Not to mention the baby is forever moving and changing position which just adds to the confusion. One of the technologist at my site recommended drawing out the different fetal positions by using a transverse view and showing how the spine is in a different position depending on how baby is laying, I think I will try that this week!

Hi Brittany,

Awesome pictures in your post! I love how you broke it down starting from the cervix and then analyzing what you have on the screen. It is like putting a puzzle together. For me, I used Dr. Wilson's tip and used my teddy bears one as mom and the another tiny one as the baby and would practice like that. The CIs at my site also like you said do a quick sweep to check where the spine and head are and get a good idea of the baby's position.

Thank you so much for sharing this Brittany!

This + that afternoon where you and Allison explained in lab with the paper doll how to determine fetal presentation, really helped me. I agree with Chrishawna, this is a great thing to have in our binders for clinic, I actually already formatted it into a  word document! (:

Such a great reminder!!!

I don't think I will ever forget doing this in lab together! I think the coronal sweep noting where you are pointing the transducer on moms belly as you see the fetus spine to fetus belly then following up with a transverse view looking for the location of the spine in correlation to the screen might be a fool proof way of figuring out fetal lye. By the way this is much easier to explain in lab while actually doing it.

Hi Brittany! 

I just wanted to join everyone and say that this is a great post! Are you sure that you're struggling with this concept? You look like a pro! 

I think, maybe its just being exposed to many OB scans, will bring you a lot more clarity! You're about to be killing it for your first hands on OB! 

Your post has definitely helped me. I comprehend things in little bites, so I GREATLY appreciate this.

Hi Brittany!

Great post my love!

I also have had an issue with fetal presentation. I love the tips and game plan you have to master it. I've noticed that imaging baby's fetal and then immediately followed by situs helps me get baby's position in my head easier. I also have to act as if I'm in the mom's belly sometimes lol to fully get the presentation.

Hey Brittney,

 This post is absolutely amazing!!! This is so helpful for me how you broke it down. I am going to right this out and try to apply it at clinics. I am also going to try and print that picture out as well. Thank you so much, this was great! 

OMG LEAH! I love Dr. Filly's video and shared it in my post as well. I think it helps to keep watching it over and over and I just answer his questions before he tells the answer and pause the pictures that he has and try to see what structures I can see correctly.

Let's say you are scanning a baby and cannot get all the heart views you need, how do you go about this? Would you try to get all the heart views at once or move on and come back?

Hi leah!

Wow thank you for all these helpful videos! I definitely am still getting the heart views down. I feel like I struggle with it because I don't get OB at my site. So sad. A patient was asking me things today and I told I wish I was getting more exposure to OB because it's what I'm learning right now. but there will come a time! Are you getting used to heart views at all in clinic? 

These are such great videos!! Thank you Leah!!

Hi gorgeous,

For me I think repetition is key and helps to make the material we learn second nature. I like to use the website slideshare; it has really nice presentations made by people that are simple and easy to follow. Here are two that I liked the most on fetal circulation:

https://www.slideshare.net/binuenchappanal/fetal-circulation-124643432?qid=f812c075-3760-465e-ae73-e3ba9c22ac64&v=&b=&from_search=10

https://www.slideshare.net/arvindyuvaraj/fetal-circulation-79357601?qid=f812c075-3760-465e-ae73-e3ba9c22ac64&v=&b=&from_search=6

I love NerdNinja too so here is  short video of his that I watch occasionally to refresh this topic: https://www.youtube.com/watch?v=z1r6N168faw

As sonographers our job is to document images so knowing the outflow tracts and getting heart vessels makes sense, but why do you think it is important for us to know the blood circulation of a fetus?

Hi Lania. There is definitely a lot going on with the fetal circulation and it was confusing me at first too. What I found helpful was nailing down normal non-fetal circulation first since it follows a more straightforward path. I watched the video below a couple times to lock it in. Then I incorporated the additional fetal circulation pathways on top of that, like the foramen ovale, ductus venosus and such. I know everyone learns differently, but I hope it's helpful!

Hi Lania!

Not sure if anyone has shared this video yet:

It's from the Khan Academy and they always do a great job of breaking things down into a digestible format. This one really helped me.

Hey Lania, 

 I hear you gal, fetal circulation is not easy at all. I think these graphics are great and should further help solidify you understanding. If drawing is not helpful, I suggest getting a white board or blank sheet of paper and writing it of memory and correcting you mistakes with red and then repeat until you dream about fetal circulation  ;  ).

Hi Chrishawna,

I mentioned this earlier in another post but I used my teddy bears to help me with fetal postions :) It is a fun and cute way to learn these difficult concepts. I struggle with the outflow tracts as well and always try to see them as I watch my CIs scan OBs. I think the picture you used shows a bit how to angle our transducer up and down to get different views. Here is a website that shows the views we get and how one should angle their transducer to get those views: https://www.ultrasoundpaedia.com/normal-fetal-heart2/

When scanning OB cases, do you try to go system by system so get all the heart views all together or do you think its better to just get what you can and then move on?

Hey Chrishawna, 

 I am with you girl! I struggle in the same areas as well. What kind of doll are bringing? I was thinking about doing the same thing because I am really struggling as you know from us practicing this past Friday. I just don’t want to bring anything to distracting for my tech. I honestly don’t get much practice at all getting heart views so I don’t have much advice to offer except that I know the moments are very subtle, to where the mother can breathe and it can change the view. Maybe these videos can help: 

https://m.youtube.com/watch?v=rW2r55AS3Xk

https://m.youtube.com/watch?v=jDl_XpGUJEU 

One day the heart will be a breeze for you gal. 

Hi Candee,

Ugh embryology is definitely something else lol. Here is a cute pnemonic that I found that you may find helpfu:

1. foregut : """ BILL & PEGGY ON LSD "" (P=pancreas. E=esophagus. G=gallbladder. L=liver. S= stomach. D1,2 = duodenum 1 and 2nd parts. BILL = Biliary apparatus.
2. midgut = JAILED CAT. ( J=jejunum. A=appendix. il=ileum. D=duodenum 2,3,4 parts. C=cecum. A=asc colon. T=trans colon prox 2/3.
3. hindgut = DESCENDING RATS.

http://www.usmleforum.com/files/forum/2008/1/285338.php

Sometimes it is easier to learn a concept if we start from the end results rather than the beginning. So, what issues do you think can arise if the GI tract does not divide and form correctly?

Hey Candee, 

I also have a hard time nailing this down, i get the general idea but what happens at what specific time is what kind of confuses me a bit.

https://youtu.be/dbVOIR5QaLc

https://youtu.be/Dq3F4yby0qo

found these youtube videos for more clarification!!

Hey Lauren

That's so funny, I watched the video that you posted a few times before and it has really helped me learn fetal circulation but also just drawing out the cycle multiple times have really helped as well. 

Hi Allison,

I struggle remembering dates too, especially measurements! I always try to come up with mnemonics or use the letters of a word to help me remember. Like with Hepatitis A I think of the "A" as standing for an Acute disease process. Sometimes I will even use the amount of letters in a word as a clue, for  (a made up ) example, if the bladder were to be visualized sonographically by week 7 of GA, I would recall this by using the seven letters that make up the word bladder! Sometimes its a stretch, but it can be beneficial too!

Hi Allison! I agree -- keeping all the important events and dates in line is a doozy. I started making this chart to help me organize it all. It's not done yet, but I can put a copy on the google drive if you think it would be helpful. I also made a separate chart for the anatomy scan measurements.

Hi Allison,

For the dates, my CI has this wheel she uses to check important measurements. I will bring it to class one day to show you all.

I was chatting with my techs today and they gave me some advice to get the LVOT and RVOT views. When you get the 4 chamber heart, angle the probe slightly towards the baby's head to get LVOT and then tilt towards the baby's right shoulder to get RVOT. The movements are very minuscule and be sure to keep in mind the baby's position when deciding which way to tilt your transducer. For instance, if the baby is in the cephalic position then the right shoulder would be downwards.

Hopefully this helps and you can try these tips at your site soon!

Same here Raman,

I get a 1st trimester once in a blue moon and sometimes theres no baby in there so I'm basically just doing a pelvic exam, so sad. I was just saying the same thing in Leah's post about how I don't get to practice what we're learning and it's such a bummer. Hoping I get some exposure soon or at my next site! until then, keep the videos coming lol 

Hi Hailey,

Fetal circulation is a toughy to remember. I like to look at images because SOMETIMES visual learning works for me. Hope this helps you and whoever else needs the refresher!

Hi Alexis!

I struggle with this too. I try to remember short axis RVOT by remembering it looks like a snail! I believe that the long axis RVOT can either be taken slightly above the 4 chamber view like the LVOT or it can also be taken in the 3 vessel view.

I think the preference of these types of RVOT views typically depends on the radiologist's preference. At my site the tech actually did both views because she wanted to show where the ductus arteriosus meets up with the aorta (long axis view) and the bifurcation of the pulmonary artery (short axis view).

I think Dr. Wilson also said that a lot of radiologists like the short axis RVOT view to prove that it does in fact bifurcate.

Hi Molly!

Fetal lie is a difficult one sometimes! I'm not sure if its at the very beginning of your protocol too, but I've found those initial rt to lt and inf to sup sweeps to be so essential for me determining lie right away! I had some trouble at the beginning because I would see, for example, feet at the cervix but the rest of the baby was lying sideways in the uterus so I would call it transverse. My CI had to tell me at least once "however the baby is lying more superior, if feet are at the cervix, they're breech". I had to look up transverse lie images this weekend too since we see that less and I can never confidently say transverse, so if we see abdomen presenting to the cervix or maybe upper extremities, they should be transverse. 

You found some great images, so I think it's one of those things we just have to scan a few times and get more confident with to be sure!

Hi Molly,

I agree with you 100% fetal heart views and presentation are my kryptonite! I think one of the things that makes fetal heart so difficult is that a lot of the time is position dependent. While we may be able to see it, it doesnt always mean the baby is in the ideal position to capture an image (especially one a radiologist would approve). I always feel like I have "dumb luck" when it comes to heart, when I am not trying I can get a beautiful RVOT without even realizing or attempting to. I can't wait for the days when we have it down and we know exactly how to move our probe to get those desired views! When it comes to fetal presentation I had a small breakthrough today, I literally imagined I was the baby in the uterus and my mind was able to conceptualize how that position correlated with the image. I literally spent a decent amount of time talking to myself and squirming around in my chair before I felt confident with my answer lol. We just have to keep reminding ourselves that one day it will all make sense!!

Wow Molly I love these images, I've been trying to picture fetal position in my head because I don't see a lot of OB at my site. but today i got to observe a 3 trimester follow up! I was so excited. I wasn't able to scan her because she was a double study and she was already there for a while so the tech just did it real quick. but I learned a lot from it because they tech was walking me through it as she was scanning which was nice. 
Anyways congrats on the LVOT girly you're doing amazing!!

Hi Zuly!

Fetal circulation can definitely be tricky. It helps me to first remember normal adult circulation and then add in the "short cuts" that fetal circulation can take.

I like to remember that there are 3 short cuts - ductus venosus to bypass liver and get into the IVC, foramen ovale to bypass the right ventricle and enter the left atrium, and the ductus arteriosus to bypass the lungs and get straight into the aorta. 

Here's an image of normal adult circulation to help you compare the differences between the two! :)

Thank you for sharing those slides, Zuly! I’ll definitely be quizzing myself with those before the final. 

Hey Nailah!

I feel like we're all working on improving on the same topics, these are definitely the most challenging to nail down. I love that you mentioned going back to the basics, and revisiting the scan planes. I love this image Sue shared with us demonstrating uterine presentations transabdominally and how they will appear on EV. Scanning EV definitely flip flops my brain if the patient has a retroverted uterus!

Howdy Nailah,

In order to determine fetal position I like to first check the cx area. Do I see a head, feet. or part of the torso? This will determine if baby is cephalic, breech, or transverse. Next, place the transducer at a 90 degree angle with the bed. Find the head and slide the probe from right to left. Do you see a face first or do you see the nose and lips come in after you've scanned through the head? This will determine if baby is facing right or left. This assumes baby is cephalic or breech. Adjust for transverse presentation as needed.

If you don't see baby's nose/lips this way, then baby may be spine up or spine down. Check by scanning at a 90 degree angle with the bed. Is the spine directly in line with the transducer beam? Is the spine closer to the footprint or further away? You may need to look transverse and long to double check.

Hope this helps,

Sarah

Hi Monica,

I totally agree with you and struggle with heart views as well. :( I noticed when I see the views on paper I am able to somewhat understand it but when I watch a tech scan, I get so confused and am not able to follow along. I remember that Sue was saying as a tech our eyes are always on the screen and she does not pay much attention to what her hand is doing. Since you scan OB at your site, do you try to angle to get your different heart views or do you just get a 4 chamber and follow the screen to see what you can get? I feel a lot of sites say to angle a certain way but in reality when working with a moving baby (especially  a hyper one) that may not be the most practical approach.

Hey Monica!

Heart views is something I can understand visually, but to actually get them sonographically is something entirely different!

Do you get to scan at all, or do you have to just observe for now? I feel like getting hands on experience is really key to getting these different views!

I've compiled some different scan planes for fetal heart that may help us.

Hi Monica!

I'm with you love! Some days I get them and some days I don't get it at all. I've been watching YouTube videos to try to help which I find helps me recognize what each view should look like but it doesn't necessarily help me find the actual heart views. My CI told me that one day it just clicks and the best way to learn it is just to keep scanning it and it eventually becomes like muscle memory! So we will get there one day! But like you said, nothing good is ever easy, but we got this!

Hi Karen,

Thank you so much for sharing such an informational image! I am going to print it and put it in binder. Very simple and easy to follow.

Why do you think knowing embryology is so important for OB? I was asking some of the techs at my site and they did not know some of their embryology lol

Thank you for this Karen!!

One thing I for sure struggle with the the urogenital system embryology!! This image really helps!

Here is another that I like as well.

Karen! 

This diagram is so cute and educational! Thank you for sharing embryology. I needed this as well.

During break, we should work on a graph/ diagram that helps us out with memorizing the normal measurements. 

So happy to be going through school with you ladies!

Hi Karen! I feel you on reading questions too fast. It's always a bummer when I re-read it after and I know the answer >.< 

I made this chart to help me organize the anatomy scan measurements. I think I may want to add renal pelvis measurements though, just in case there is questionable dilation. If you can think of any other ones I missed, please let me know!

Hi Sarah!

Cervix is always a struggle for me as well... Usually it's not as clear as this but I found a nice example for measurement!

 We may just need to angle better to fully utilize bladder as a window.. but I think sometimes it's just hard to really see. I'm guessing this is where years of experience comes in, haha.

As far as development, I found this great chart! It includes time where baby is most at risk for abnormalities, which I thought was really interesting. I'll probably be referring back to this if/when the time comes for me to have a bun in the oven!

Hi Sarah!

I totally understand where you are coming from. I struggle with this from time to time. The best advice that my CI gave me was to just get as much exposure from OB. There's a lot that can change the appearance of the cervix/ os and placenta images (Braxton Hicks contractions). The cervix could look different due to the mother's bladder or  the fetal head giving us some side wall shadowing! It's important to just take a deep breath and remember the landmarks that Karen's image shares above. Overall, I think you're doing great! 

Hey Sarah,

The trans cervix is hard for me too especially if the woman is not pregnant. I think its more of a judgement call but it kind of seems like early on in the cycle it is harder to tell but once the endometrium gets thicker you can kind of see it thinner in the cervix area 

This image kind of shows it best! See where the endometrium gets thinner and the cervix tissue also is a bit more hyperechoic.

Hi Sarah,

I always remember that the rhombencephalon is seen around the 7th week.

Rhomben-SEVEN-lon!

Hi Sarah!

I too struggled with seeing cervix and still do a bit, but my CI told me a trick to look for the shape of a U. It can be hypoechoic or a hyperechoi or even homogenous which I think is what trips me up because everyone's cervix can look different, but once she told me that I started looking for the U shape and found it a bit easier to spot. I hope this helps a bit! :)