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Thinking beyond the scan - adopting a holistic approach to pregnancy care

2 October, 2019

Author: Ellen Dyer, Sonographer. The Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust

What do you think of when you think of advanced practice in sonography? 

Fine needle aspiration? Contrast enhanced ultrasound of the liver?

As a sonographer specialising in an often-forgotten specialty, obstetrics, I would like to suggest that there is more to advanced practice than just intervention, and that perhaps exceptional patient care should also be considered advanced practice. After all, obstetric sonographers are an integral part of the team looking after pregnant women.

During my undergraduate training as a radiographer, I was taught not to disclose information to patients. Despite this, I believe that as autonomous practitioners, sonographers have a duty of care beyond scanning and reporting, an idea supported by Health Education England’s Make every contact count programme. Sonographers have a unique opportunity to help women and improve their pregnancy journey, just by talking to them.

In my opinion, we should all be listening to what pregnant women tell us during their scan appointment. Why? Because they may tell us something clinically relevant.

But first we need to think about how we communicate with women and how we can build a rapport with them quickly. To do this we need to consider the key elements of effective communication. The first may seem obvious, but I would encourage all sonographers to read their service user’s medical notes before calling them into the scan room. Find out as much as you can about them; there is nothing worse for a woman than having to repeat their entire medical history to every healthcare professional they meet. It does not instil confidence! By having a quick look through the notes, it is possible to identify any relevant clinical information and it may even help with image interpretation during the scan.

For example, the reason why a woman has enlarged ovaries at the dating scan may be because she has recently undergone ovarian stimulation as part of IVF treatment. Beyond this, you want to make sure you have identified any other issues that may impact on the pregnancy, such as existing medical conditions, safeguarding issues, and previous obstetric or gynaecological history.

Have they had any extra hospital attendances during this pregnancy? If so, why? Reading the notes only takes a few moments but makes a big difference even to low-risk women. By demonstrating that you know a little about your service user, even it is just that they are a first-time mum, the person will trust you more. 

The second element to think about is the language you use. After introducing myself and checking demographics, I always ask an open question about how the pregnancy is going so far, a tip I picked up from a counselling course some years ago. By asking an open question like this, it gives the woman an opportunity to tell you about anything which is bothering them, and it is amazing what they will tell you! Okay, some of the things mentioned aren’t always relevant, but it is a combination of the seemingly trivial things described that frequently lead me to refer for further assessment. Here are some examples:

  1. Frequent and severe headaches with or without swollen hands or feet. Pre-eclampsia could be a possibility. Refer for a midwife review and blood pressure check.
  2. Itchy hands and feet. Obstetric cholestasis could be a possibility. A medical review may be needed.
  3. Persistent PV spotting with no cause demonstrated on scan. The patient should consider making an appointment with their GP for a speculum examination to check the cervix. 
  4. Difficulty getting on and off the couch. I ask if they are experiencing pelvic pain and whether it is affecting their sleep. If it is, I would refer them to the pregnancy related pelvic pain clinic run by our physiotherapy team.
  5. Pregnancy anxiety. I ask if their anxiety is affecting day to day life and/or sleep? If it is, I would suggest they make an appointment with their GP.
  6. A patient appears withdrawn, or has unexplained bruising. If they are on their own, I ask about mental health, domestic violence, and perhaps contact their community midwife, mental health midwife, or our safeguarding midwife if I have concerns.
  7. New disclosure of smoking in pregnancy. I would discuss the need to inform her midwife so that carbon monoxide monitoring and a referral to a smoking cessation advisor can be arranged. There is an increased risk of stillbirth with smoking and additional growth scans will be required. Smoking cessation is a key element of Saving Babies’ Lives Care Bundle Version 2.

The list above is by no means exhaustive, but hopefully highlights some of the conditions obstetric sonographers should be aware of and how to make appropriate referrals for further review. It is important from a medico-legal perspective to document all relevant information disclosed by the patient in your report and detail referrals made in accordance with department protocol. Having said that, it may not be appropriate to document safeguarding issues on the patient copy of the ultrasound report. 

You may consider much of what I have discussed to be the responsibility of midwives, but I would argue that this is not the case and that we all have a part to play, particularly as many women will only see their midwife two or three times before the third trimester.

You may be concerned that adopting a more holistic approach to pregnancy care may create extra work for midwifery, physiotherapy, obstetrician and GP colleagues. From experience I have realised that my colleagues would much rather I call them to discuss any concerns than just send a woman home. 

After all, we are a multi-disciplinary team with the same objective: the nurturing of happy, healthy mums and babies!

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