Comparing the effectiveness of training course formats for point‐of‐care ultrasound in the third trimester of pregnancy

Abstract

Introduction

The availability of obstetric point‐of‐care ultrasound (PoCUS) services has been shown to improve pregnancy outcomes in regional and remote areas both in Australia and around the world. There is an increasing demand for efficient, cost‐effective PoCUS courses for monitoring the fetus in the third trimester of pregnancy.

Aim

To compare the effectiveness of targeted PoCUS courses provided for health professionals that assess the fetus during the third trimester of pregnancy.

Method

The skill‐teaching curriculum and competency outcomes of six obstetric PoCUS courses were compared. There were 55 learners with no prior ultrasound experience including 23 with English as a second language. Course duration ranged from 4 to 18 h, didactic lecture time up to 6 h and practical scanning sessions of 3–12 h. Learner/tutor ratio varied from 1:1 to 6:1. All courses included the teaching of knobology, image optimisation and probe manipulation. Practical sessions included supervised scanning of ultrasound phantoms and scanning women in the third trimester of pregnancy. The teaching outcomes that were assessed included image optimisation, determination of fetal lie, fetal heart rate, measuring the single deepest pocket of amniotic fluid, identifying the placental position and basic fetal biometry. The same pre‐ and post‐course multiple choice test and course evaluation forms were used for every programme.

Results

All participants achieved the limited course objectives, regardless of the differences in the course formats.

Conclusion

This study confirms that obstetric PoCUS courses can provide the initial basic knowledge and scanning skills required to perform limited scope third‐trimester scanning.

Introduction

Ultrasound has become an invaluable component of obstetric care with access to this imaging modality having the ability to improve the pregnancy outcomes for both mother and baby. The World Health Organization (WHO) statistics on maternal mortality show that, worldwide, over 830 women die each day from preventable complications of pregnancy and childbirth.1 The risk is increased in rural and remote regions and in low‐income communities, with more than half the deaths occurring in sub‐Sahara Africa and a third in South Asia.2 Obstetric point‐of‐care ultrasound (PoCUS) has been shown to reduce this maternal mortality rate by answering basic questions such as fetal number, fetal lie, whether there is a heartbeat, gestational age, the deepest pocket of amniotic fluid and the position of the placenta.3 A limited scope ultrasound scan in the third trimester of pregnancy may identify issues that could change the patient's antenatal plan and lead to an improved outcome. The international ultrasound community is aware of the need for ready access to obstetric PoCUS and has responded accordingly with the provision of outreach programmes via groups such as the Australasian Society for Ultrasound in Medicine (ASUM), the International Society for Ultrasound in Obstetrics and Gynaecology (ISUOG) and the World Federation for Ultrasound in Medicine and Biology (WFUMB).4, 5, 6, 7

The wider use of this affordable modality may be restricted not only by access to ultrasound equipment and a lack of suitably trained practitioners to perform the examination, but also by regulations that could restrict the delivery of services by authorities deeming that only certain medical practitioners can perform the examination. The problem of access of ultrasound for all is seen in both high‐ and low‐resourced countries. Sippel et al.8 reviewed the literature on the uses of ultrasound in the developing world, including the differences in available training programmes and whether medical practitioners, midwives or other allied health personnel were involved in scanning. The results were broad‐ranging, but a common emerging theme centred on requests for targeted ultrasound training. Position statements on obstetric ultrasound have been released by multiple professional societies both in Australia and overseas with varying views on who can perform the scan.9, 10, 11, 12

There is an ever‐increasing need for ultrasound training programmes to be delivered in regional and remote locations for a broad cohort of operators which include medical practitioners, midwives, nurses and other healthcare professionals. The courses can be delivered at antenatal clinics or other medical facilities to use their training expertise and resources. Importantly, the location, or where the education is delivered, should not change the standard required of the training or the curriculum offered to the learners. All training programmes need to be run in a way that ensures they are cost‐effective, time‐efficient and deliver learning outcomes that align with the standards of practice for the professional cohort. In particular, performing focused or standard medical ultrasound involves the learner gaining a knowledge of the theory, psychomotor skills to perform the scan and the professional practice attributes to execute and interpret the scan to a given standard.

Nicholls et al.13 have published extensively on the psychomotor skills that are required to perform a medical ultrasound examination. Acquiring these skills represents a challenge for most learners as, when the task is new, the learner does not yet have knowledge of the acoustic windows, transducer movements, standard of performance for core examinations or how to move and manipulate the transducer.13 Importantly, Nicholls et al. (2016) have pointed out that when the task is complex, such as a medical ultrasound examination, the whole task should not be taught in one teaching session but rather, the educator should simplify the task to be taught and learned. A key instructional step involves breaking down the task into subcomponents and then teaching each of the steps until all the subtasks have been learned and practised. The learner then practices the reconstructed whole task. Nicholls stresses that scanning skills are complex and therefore the instructional approach that an educator uses to teach complex psychomotor skills should be aligned with the theories and principle of the motor learning domain. Although the model has not yet been evaluated to teach a complex psychomotor skill such as medical ultrasound, the authors suggest using an 11‐step instructional model. This model suggested by Nicholls et al. (2016), in conjunction with didactic lectures, was used as a framework to guide and inform many of the pedagogical approaches that were used to teach a mixed cohort of learners the skills to perform basic third‐trimester ultrasound examinations. However, teaching learners the skills to become safe operators of ultrasound equipment is just one dimension of delivering a structured course, to adult learners.

Course evaluation by participants has been shown to assist tutors and course providers with improving the format of offered courses to ensure they address the needs of participants. The New World Kirkpatrick Model of training evaluation is an example of an outcome‐focused method that is well adapted for medical education.14, 15 It involves four levels of training evaluation: reaction, learning, behaviour and results. The first level, reaction, looks at the level of satisfaction with the course, the level of participant engagement, particularly in the hands‐on sessions, and finally if what has been taught would be relevant to their work situation. The second level is about the participants learning outcomes. This looks at knowledge, or what they know, what skills can they presently perform, do they have a positive attitude about the training and are they confident and committed to continue scanning once back in their clinics. The third and fourth levels, behaviour and results, although not relevant to the immediate post‐course evaluation, can be applied to those participants who are followed up in latter months. These levels look at whether participants apply what they have learnt once back in the workplace and whether they are encouraged and rewarded for positive outcomes.

Aim

The aim of this project was to compare and evaluate the effectiveness of a variety of targeted ultrasound point‐of‐care short training programmes that assess the fetus during the third trimester of pregnancy.

Methodology

Over an eighteen‐month period, the skill‐teaching curriculum of six obstetric PoCUS courses was compared and outcomes evaluated. The same lead tutor conducted all the didactic lectures and skill sets for every course with experienced obstetric ultrasound tutors assisting students with the hands‐on sessions. Although the information and core skill sets taught remained the same for every course, the specific parameters varied, with differing times for both the didactic and hands‐on components (Table 1).

Table 1.

Summary of courses

Site	Student number	Course hours	Lecture hours %	Practical hours %	Tutor: student
1 City Hospital Australia	20	4	1 (25%)	3 (75%)	1:5 ratio
2 Rural Hospital Australia	8	10	4 (40%)	6 (60%)	1:4
3 Private Hospital Australia	4	4	0	4 (100%)	1:4
4 Women's clinic Timor Leste	5	12	4 (33%)	8 (67%)	1:5
5 Rural clinic Indonesia	10	5	3 (60%)	2 (40%)	1:2
6 Rural Hospital Central Asia	8	18	6 (33%)	12 (66%)	1:4

Of the six courses evaluated, three were conducted in Australia and three overseas. There were 55 learners in total including 15 medical practitioners, 23 midwives, 9 nurses and 8 radiographers, none with any prior ultrasound experience. Twenty‐three of the 55 learners had English as a second language (EASL) and included three medical practitioners, 10 midwives, two nurses and eight radiographers. Each course had between 4 and 20 participants. Course duration ranged from 4 to 18 h, didactic lecture time to 6 h (0–60%), practical scanning time 2.5–12 h (60–100%) and tutor/learner ratio from 1:1 to 1:6. The course details were as follows:

1. Training for 11 obstetric residents/trainee general practitioners (GPs), five midwives and four nurses at a major Australian city hospital utilising an ultrasound department facilities

2. Training for a GP, three nurses and four midwives at an Australian rural hospital utilising one hospital ultrasound machine and loaned portable systems

3. Four midwives at a private hospital in a major Australian city using state‐of‐the‐art systems

4. Medical practitioners, a nurse and three midwives at a clinic in Timor Leste utilising a portable unit

5. Seven midwives, a nurse and 2 GPs at a rural clinic in Bali that catered for antenatal care and birthing using loaned portable units

6. Eight radiographers at a newly built training room within a rural hospital in central Asia using new mobile units.

Course formats

The course learning objectives were as follows:

1. To obtain and optimise an ultrasound image with depth, focus and gain controls and to correctly move the ultrasound probe

2. Confirm presence of fetal heartbeat, determine fetal lie and placental position and identify basic fetal anatomy such as heart, stomach and bladder

3. Measure fetal heart rate, the single deepest pocket of amniotic fluid and measure BPD, head and abdominal circumference and femur length.

All courses included a pre‐course multiple choice test to determine prior ultrasound knowledge of the participants. In the courses with EASL participants, an interpreter was available to translate questions and choice of answers. The skill set teaching component was identical for all courses. The first component was a basic explanation of how ultrasound works and the ultrasound machine controls for changing depth, gain, time gain compensation (TGC) and focus if applicable. This was followed by how to hold the probe, describing the correct screen orientation and the ultrasound scanning planes. Teaching probe manipulation was accomplished using simulative teaching methods where participants used wide plastic serving spoons as mock sector probes to practice the basic movements of sliding along the probes wide and narrow axis, angling in the wide axis, angling or ‘heel/toe’ in narrow axis and rotating the probe from transverse to sagittal planes. For one group of four midwives, rather than the didactic presentations, an interactive hands‐on approach using the machine and a scanning phantom was used to cover machine controls, orientation and probe manipulation as well as discussing the importance of clinical history and the recognition of fetal and uterine anatomy whilst scanning volunteer pregnant models.

Following didactic lectures and depending on the number of tutors, the class was split into smaller groups to practice using the machine controls and defined skill sets, such as image optimisation of depth and gain and probe manipulation. The ultrasound machines used in the courses were a mixture of site owned or borrowed from manufacturers for the course duration. Commercial or homemade phantoms were employed for practising machine controls and probe movements. Experienced tutors assisted the participants in all aspects of the practical sessions including correcting probe grip, prompting with the adjustment of probe movement, machine settings and anatomy recognition. Participants were encouraged to ask questions of the tutors during the hands‐on sessions.

Interactive lectures addressed the limited scope clinical component whilst covering the essential knowledge required to underpin a PoCUS pregnancy ultrasound. For example, it was important for the learners to know the importance of seeking a clinical history to determine how the pregnancy had progressed to date. Other essential information included knowing the theory to be able to perform a limited fetal anatomical assessment and, if applicable, fetal biometry in the third trimester of pregnancy. Finally, it was important to cover the key theory related to the operator being able to identify fetal; number, presentation, heart rate, the placental site, and measure the single deepest pocket of amniotic fluid. Five courses also included an emphasis on how to perform basic fetal biometry such as head circumference (HC), biparietal diameter (BPD), abdominal circumference (AC) and femur length (FL). A critical aspect of all the courses was the availability of supervised hands‐on scanning of pregnant women who were in the third trimester of pregnancy. As per the recommendations of Nicholls et al.13, the scanning skill sets were simplified and taught one at a time with the task initially being silently demonstrated by the tutor before the skill was practised by the course participants. The initial scanning task was a slow sweep up the midline of the lower abdomen from the symphysis pubis to the xiphisternum in the transverse plane to identify fetal lie based on what anatomy could be identified.

There was access to multiple volunteer women in the third trimester of pregnancy for all courses, and so participants were each able to complete a minimum of four examinations under the supervision of tutors before undergoing a scanning skill assessment. A checklist was made available to ensure that all required scanning components were completed and included image optimisation, probe movements, determination of fetal lie, measuring of fetal heart rate, recognition of fetal anatomy, measurement of the single deepest pocket of amniotic fluid and the identification of the cervix and placental position. Fifty‐one participants were also assessed for capturing correct images to perform fetal biometry measurements.

Participants completed a post‐course multiple choice test, identical to the pre‐course test, to assess their level of understanding of what was taught during the programme. At the conclusion of the final session, the participants were asked to complete a course evaluation. The course evaluation questions looked at the level of satisfaction with the course, the level of engagement and if what they learnt would be relevant to their work situation. Other questions asked about their understanding of lectures, if they felt they could confidently perform the scanning tasks and are they committed to continue scanning once back in their clinics.

Follow‐up assessments

Thirty‐one learners received follow‐up assessments between six and eleven months after the completion of their initial course. The same pre‐course multiple choice test from the original course was used and expanded to include questions on whether they have been encouraged to use ultrasound in their everyday practice, had they applied what they learnt in the initial course, did they feel confident in their scanning skills and had it made a positive difference to patient outcomes in their clinics.

The next step of the follow‐up was to comment on a series of images. A visual format with a set of images displaying correct and incorrect settings for depth, gain and measuring was used. The final segment was scanning a third‐trimester pregnancy and assessing fetal number, fetal lie, heart rate, deepest pocket of amniotic fluid and placental site as well as imaging and measuring the BPD, head and abdominal circumference and femur length.

As the courses were conducted in multiple locations, both in Australia and overseas hospitals, clinics and private colleges with volunteer pregnant models, no ethics approval was sought for this work.

Results

Regardless of the mix of the course format, all 55 participants achieved the limited course objectives, being able to independently obtain and optimise an ultrasound image with depth, focus and gain controls and to correctly move the ultrasound probe. When scanning a pregnancy in the third trimester, they could confirm the presence of fetal heartbeat, determine fetal lie and placental position and identify basic fetal anatomy such as heart, stomach and bladder, measure fetal heart rate, the single deepest pocket of amniotic fluid and, if applicable, measure BPD, head and abdominal circumference and femur length. Five EASL learners, 4 midwives and a medical practitioner, were unable to complete all of the post‐course multiple choice questions due to the language barrier as no interpreter was available. Theses learners had all completed at least 50% of the multiple choice test correctly and although other students offered to interpret the questions, it was felt that this could have introduced bias. This interpretation offer was accepted so that these EASLs could complete the course evaluation.

The participants were very positive with their responses for the course evaluation with all 55 saying they understood what was taught, the relevance to their clinical work and their commitment to continue scanning on their return to their clinics.

Every participant returned to their workplace and continued to scan pregnant women.

Post‐course follow‐up to assess skill retention was conducted on 31 learners, 21 from Australian courses at 6 months and 10 from overseas courses at 11 months. The Australian group included eight medical practitioners (four urban, four rural), 11 midwives (three urban, eight rural) and two nurses (one urban, one rural). All 21 participants correctly identified the best image examples from the visual exemplar and identified fetal anatomy during the scanning assessment. For the practical scanning assessment, eight doctors and nine rural midwives and nurses all required minor prompting for image optimisation of depth and gain and correcting of the imaging plane for the fetal biometry. The remaining four midwives and nurses were from an urban clinic where they had had peer support since completing their course and this was reflected in their competent scanning skills for not only the image optimisation but for recognition of anatomy and capturing of images for measuring of fetal parameters.

The overseas group, two doctors, seven midwives and one nurse, were followed up 11 months post‐course with eight passing the visual assessment and 6 of the 10 successfully completing the practical test with minimal prompting. Of the 4 midwives that failed the practical assessments, none spoke English, with two of these midwives also failing the visual test. Encouraging these four learners to scan additional patients enabled them to demonstrate that they could perform a basic ultrasound to the required standard.

Discussion

This study was an extension of previous work to compare the effectiveness of targeted obstetric ultrasound point‐of‐care training programmes for assessing the fetus during the third trimester of pregnancy.16 The scenario of every participant from every course assessed in this study returning to their workplace and continuing to scan pregnant patients is not often the case. In many clinics, there is no available ultrasound equipment or the equipment they have access to is very old, poorly serviced with inadequate probes. The differing course formats evaluated in this work did not impact on the learning outcomes. The learning objectives of all courses were achieved by every participant as were the limited scanning competencies. This is a reflection of the experience of the tutors involved and the commitment of the learners to further their skills in their individual clinics.

The provision of obstetric PoCUS courses and the resultant health providers capable of performing basic scans has made a significant impact on the accessibility of ultrasound to women in remote regions. This statement is supported by literature from Kenya, Libya, Rwanda, Tanzania, Uganda and Zambia.17, 18, 19, 20, 21, 22, 23 Vinayak et al.17 conducted a highly successful training programme for rural midwives in Kenya. Using a tablet platform and mobile phone transmission technology, the Kenyan midwives scanned patients to a set protocol then contacted radiologists in Nairobi to assess the images prior to the patient leaving the clinic. There was a 99% accuracy rate which has prompted the training programme to be extended to include more midwives. There was a similar programme in Uganda which reported that following a focused 6‐week training course, midwives were highly capable of performing limited scope ultrasound to identify high‐risk pregnancies.22 A pilot project in Zambia concluded that although midwives trained to perform basic obstetric ultrasound positively impacted clinical decision making, more data were needed to determine whether access to ultrasound in rural areas improved clinical outcomes.23 Shah et al.24 surveyed healthcare providers who performed ultrasound in low‐ and middle‐income countries in Africa, South America and Asia to ascertain the barriers to increasing the use of ultrasound. The respondents to the survey identified a lack of suitable ultrasound education as the primary reason for not making ultrasound more readily available to the pregnant women in their regions.

Conclusion

The courses assessed in this work varied in length and time spent on didactic lectures vs. hands‐on scanning. All courses taught the basic knowledge required to perform a limited scope obstetric ultrasound examination, with all participants achieving the learning objectives. It could therefore be deduced that all of these courses gave similar outcomes. The study has confirmed that short PoCUS courses can guide the initial psychomotor skills, such as how to move and manipulate the transducer, required for limited obstetric scanning in the third trimester of pregnancy.13 However, the effectiveness of any of these course formats is reflected not only by immediate outcomes but also by the retention of skills and scanning performance beyond the course practice sessions. Continuing scanning practice with a support network is the only way to gain the full value of attending a PoCUS course.

Conflict of interest

There are no conflicts of interest.