GUSI E-newsletters

June 2023: POCUS vs. the Physical Exam in Obstetrics

We’re excited to continue our series on how POCUS can transform the bedside clinical exam.  In this month’s newsletter, we examine the traditional physical exam performed in basic prenatal obstetric care and explore how POCUS coupled with the physical exam leads to more accurate and timely diagnosis of potentially life-threatening conditions.  

Nurse midwives, family physicians, obstetricians in labor and delivery wards and prenatal clinics around the world routinely use the physical examination to answer important clinical questions such as whether a patient is breech.  

In 1846, Christian Gerhard Leopold was born in Meeran, Saxony and would devote his life to advancing the knowledge and practice of obstetrics including shaping aspects of the modern obstetric exam.   

One of Leopold’s most enduring contributions is his description and classification of the four “Leopold-Handgriffe,” or Leopold Handgrips published in the journal “Archiv für Gynäkologie,” better known today as the Leopold’s Maneuvers. These maneuvers are a series of systematic abdominal palpations performed by a healthcare provider to assess the position, presentation, and engagement of the fetus in the pregnant pelvis.

Today, Leopold’s maneuvers are an integral part of obstetric examination, enabling healthcare professionals to gather crucial information about the fetus’s position, presentation, engagement, and descent. These techniques are invaluable in facilitating safe and successful deliveries while reducing potential risks to both the mother and the baby.

It is important to note that while Leopold’s maneuvers have long been relied upon for assessing fetal presentation, advancements in technology have introduced alternative methods, such as ultrasound, for this purpose. Ultrasound utilizes sound waves to create images of the fetus in the mother’s womb, providing detailed information about its position and presentation and has significantly improved our ability to accurately determine fetal presentation. 

Highlights:

• Overall sensitivity of detecting malpresentation by abdominal exam is only 50-70%

• Routine POCUS screening for vertex position at term lowers the risk of undiagnosed breech by over 70%

• Instituting a protocol of routine third trimester ultrasound for all pregnancies was also associated with large declines in adverse outcomes of laboring in breech position including:

  • fewer NICU admissions

  • fewer APGAR scores <7 at 5 minutes

•  Overall sensitivity/specificity for Leopolds predicting vertex presentation was higher compared with previous study (93% and 96%).

• However, for large abdominal circumference, the sensitivity and specificity decreased to 53 / 57 %.

• The authors recommend routine ultrasound in the third trimester to improve diagnosis.

Case Study #1

A 32-year-old woman with a past medical history of sexually transmitted infection presents to the emergency department with a sudden onset of sharp, stabbing pain in her lower abdomen and vaginal bleeding. She is sexually active with multiple partners and had a positive pregnancy test a week ago. Her blood pressure is 98/60, and heart rate is 110. You perform an ultrasound scan of the pelvis and discover the following:

The sonogram reveals no signs of intrauterine pregnancy, but has anechoic fluid collection posterior to the uterus. Given the patient’s recent positive pregnancy test and unstable vital signs, it is likely that her ectopic pregnancy has ruptured. The next appropriate step is to send the patient to the OR.
Read more here

Case Study #2

An 18-year-old female presents to the urgent care with intermittent abdominal cramping, nausea, and vomiting. She took an over-the-counter pregnancy test at home, and it showed two faint lines. She does not want to go through another abortion, so she asked you to confirm her pregnancy. Vital signs are stable. You perform a uterus scan and discover the following (see video). What can you conclude based on the ultrasound findings?

The sonogram displays a uterus with a yolk sac, but no fetal pole lies within it. The presence of a yolk sac on ultrasound is sufficient enough to make the diagnosis of positive pregnancy. The absence of a fetal pole could be due to the pregnancy being too early. 

Case Study #3

A 29-year-old pregnant patient presents to your clinic for a routine checkup. She is 38 weeks pregnant and is wondering if vaginal delivery is an option. About 4 weeks ago, her fetus was in the transverse position. You place the probe directly above her pubic symphysis and do not find a hyperechoic rim; instead, it was found at the fundus. What position is the fetus in currently with the probe in the sagittal position assuming normal conventions?

Breech position can increase the risk of certain complications during delivery and may require a C-section to ensure safe delivery.
Read more here

Obstetrics Faculty Spotlight

Dr. Ann Lockhart, a Family Medicine and Obstetrics physician, has taught obstetric POCUS in both the inpatient and outpatient settings since finishing her residency at Contra Costa County in 2004. She grew up in rural North Carolina and found her passion for medicine while working with migrant farmworkers as an undergraduate at Duke University. She graduated from the UC San Diego School of Medicine and then specialized in Family Medicine and Obstetrics with a focus on the care of under-resourced patients. She currently teaches residents at the John Muir Health Family Medicine Residency in Walnut Creek, CA.

“Technology is best when it brings people together.” — Matt Mullenweg

POCUS Training is for everyone

If you are new to POCUS or in need a refresher, look no further.  Our next flagship in-person course, POCUS for Primary Care, will be October 5-6, 2023 in San Francisco. Don’t miss out on all the fun hands on and learning!

As an extension of the physical exam, POCUS is useful for a variety of pediatric applications like diagnosing community acquired pneumonia (with greater sensitivity than chest xray) and many others.

“Technology, like art, is a soaring exercise of the human imagination.”  — Daniel Bell

GUSI and Global Health

Ukraine 

GUSI was proud to partner with the Ukrainian FOCUS POCUS team to provide access to POCUS educational modules translated into Ukrainian.  To date, over 1000 Ukrainian medical providers have learned with GUSI.

Malawi

South Africa

Dr. Mena Ramos traveled to Cape Town, South Africa, to participate in the International Maternal Newborn Health Conference in May 2023. At the conference, Dr. Grace Githemo from Kenyatta University, Dr. Mena Ramos from GUSI, and Dr. Sachita Shah from Butterfly Network (Sr. Director of Global Health) presented the largest-scaled POCUS (Point-of-Care Ultrasound) training project. The project equipped over 500 nurse midwives with Butterfly probes and provided hands-on basic obstetric training. Within the first month after deployment and training, 88% of learners were able to identify potentially life-threatening conditions using ultrasound. The project was funded by the Gates Foundation and will continue this year in South Africa. Stay tuned for more updates!

Zambia

In April 2023, GUSI hosted another basic obstetric POCUS training for nurse midwives at the Maina Soko Military Hospital in Lusaka, Zambia.  In line with the theme for this month’s newsletter, POCUS is transforming the capacity for nurse midwives at the point of care to identify malpresentation, oligohydramnios, and placenta previa to make more timely referrals. 

Mombasa, Kenya

The GUSI Teaching Team conducted a basic lung Point-of-Care Ultrasound workshop at the Pan African Thoracic Society Conference in Mombasa, Kenya, which was met with great enthusiasm by participants! Lung ultrasound is well-studied in the literature and suggests higher sensitivity in diagnosing pneumonia, pleural effusions, pulmonary edema, and pneumothorax compared to chest X-ray.