Colour key:
Common competency framework competencies Medical leadership framework competencies Health inequality framework competencies
Fetal Medicine (2018)– approved by GMC on 10 July 2017 and implemented by RCOG on 1 April 2018
Aim
To underpin the management at Consultant level of pregnancy where there are fetal concerns.
Prerequisites
The Basic and Intermediate Obstetric Ultrasound modules must be completed prior to starting the ATSM.
Components
The ATSM contains 5 Advanced Skills Modules (ASM). ASM 1-4 are required for the awarding of the ATSM for CCT, ASM is optional 5. Outwith CCT, individual ASM may be recognised separately as part of continuing professional development towards your CPD programme.
ASM 1. Advanced Obstetric Ultrasound.
Identical to the ASM of the same name in the High-Risk Pregnancy ATSM.
ASM 2. Confirming normality and management of FASP Conditions.
ASM 3. Managing the range of fetal conditions.
ASM 4. Communication and Governance skills for fetal concerns.
ASM 5. Amniocentesis
This is an optional module for those wishing to undertake invasive procedures.
Educational Support
Attendance at the RCOG/BMFMS Advanced Ultrasound Course or an equivalent course prospectively approved by your Regional Preceptor.
Attendance at the course must be after registering for the ATSM and no more than three years prior to completing the module.
TOG, STRATOG and e-portfolio support is provided by the RCOG.
Clinical Support
The ATSM should be undertaken under the supervision of an identified fetal medicine supervisor, who must be in a position to directly supervise and assess competence as well as approve appropriate professionals to train for the wider curriculum components.
An average of least two sessions per week is required to work towards the targets. Additional, specific themed sessions are listed in the module.
Work intensity
For pre-CCT trainees the ATSM has been allocated a work intensity score of 2.0.
ASM 1Advanced Obstetric Ultrasound
Clinical competency /GMP
/Knowledge criteria
/ GMP / Professional skills and attitudes /GMP
/Training support
/Evidence/assessment
(1.01) Effective and safe use of imaging modalities(1.02) Optimise image for 2D ultrasound.
(1.03) Optimise image for Doppler ultrasound.
(1.04) Understand benefits of and indications for other imaging modalities, 3D, 4D, and MRI.
Uterine artery Doppler
(1.05) Umbilical artery Doppler
(1.06) Middle Cerebral artery Doppler, including vMax
(1.07) Ductus Venosus Doppler
(1.08) Cervical length
Ultrasound competency for the screening, diagnosis and management including timely referral of:
(1.09) Severe early onset fetal growth restriction
(1.10) Late onset fetal growth restriction
(1.11) Twin pregnancy with growth discordance
(1.12) Twin-twin transfusion syndrome
(1.13) Suspected preterm ruptured membranes
(1.14) Polyhydramnios
(1.15) Low lying placenta
(1.16) Ultrasound guided procedures: ECV for Breech / 1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1.2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2 / (1.01)
Understand the risks associated with the different ultrasound modalities and how to limit them. Understand mechanical index (MI) and thermal index (TI).
(1.02-1.03)
Be familiar with the full range of optimisation controls including, Power, gain, focal length, magnification, sector width, frame rate, pulse repetition frequency, colour and power Doppler modes.
(1.04)
Be familiar with local policies for the use and interpretation of 3D/4D ultrasound and fetal MRI.
(1.05- 1.07)
Doppler ultrasound: understand when to use Doppler ultrasound and its interpretation
Understand how these assessments are used to monitor growth restriction.
Understand how fetal anomalies may influence the waveforms (for example cardiac arrhythmias, fetal anaemia, hydrops, and twin-twin transfusion syndrome).
Understand how MCA vMax is used to monitor for signs of anaemia
(1.08)
Cervical length: transcervical measurement of cervical length, the criteria for accurate and reproducible measurement.
Recognises when cervical length should be offered.
(1.09-1.10)
Management of growth restriction according to National Guidelines. When to refer to the Tertiary Centre.
(1.11-1.12)
Multiple pregnancies: able to recognise and manage growth discordance. Understand the influence of chorionicity.
For monochorionicity to be able to monitor for signs of TTTS and refer to the tertiary centre in accordance with local guidelines.
Aware of the ultrasound features of TRAP (Twin reverse arterial perfusion sequence) and conjoined twins.
(1.13)
Aware of the role and limitations of ultrasound in the management of suspected preterm ruptured membranes.
(1.13-1.14)
Able to accurately and reproducibly estimate liquor volume using maximum vertical pocket.
Understands the associations of polyhydramnios with poor maternal glucose control, fetal anomalies, and its significance in monochorionic pregnancies.
(1.15)
Able to identify the lower edge of the placenta and measure the distance from the internal cervical os.
Recognises when there is an increased risk of morbidly adherent uterus (such as previous scar to uterus with overlying placenta).
(1.16)
Practical experience of performing successful ECV according to local guidelines. Aware of contraindications to ECV. / 1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2 / (1.01-1.04)
Appreciates the limitations of antenatal ultrasound.
Understands the appearances of artefacts and how these might be misinterpreted.
Able to explain the use of antenatal ultrasound and the benefits of the different modalities along with the transabdominal and transvaginal route.
(1.05-1.12)
Able to apply ultrasound finding to local and Regional guidelines, referring as appropriate.
(1.14)
Able to liaise appropriately to explore option of amniodrainage for polyhydramnios.
(1.09-1.15)
Able to explain ultrasound findings and management options in a manner that is non-judgemental and easy to understand.
(1.09-1.16)
Able to formulate a suitable management plan, liaising where appropriate and always considering the individuals hopes and expectations for the pregnancy. / 1,2
1,2
1,2,3,4
1,2,3
1,2,3
1,2,3,4
1,2,3,4 / (1.09-1.10)
RCOG Green top guideline No. 57 (2011) Reduced fetal movements.
No.31 (2013) Small for gestational age fetus, investigation and management.
(1.13)
Scientific impact paper No.33 Preterm labour, antibiotics and cerebral palsy.
(1.16)
RCOG Green top guideline No. 20a ECV to reduce breech presentation.
(1.11-1.12)
NICE Clinical Guideline CG 129 Management of twin and triplet pregnancies in the antenatal period.
RCOG Green top guideline N0.51 Monochorionic twin pregnancy.
STRATOG Advanced, Clinical Case Studies eLearning: Management of the SGA fetus (2016). / (1.01-1.16)
These are the ultrasound competencies for high-risk pregnancy (rather than for fetal anomaly which is covered in ASM2.)
Your evidence should be supported by a log of sessions attended and work-placed based assessments demonstrating good communication skills, documentation and recording of growth and anatomy.
(1.05-1.5)
Work-placed based assessments should include abnormal values and explore the antenatal management.
These are common findings and should be based upon direct patient care.
OSAT
CBD
Reflective Practice
ASM 1 - Advanced Obstetric Ultrasound / Part of the Fetal Medicine ATSM and the High Risk Pregnancy ATSM
Logbook / Competence level Not required
Level 1 / Level 2 / Level 3
ASM 1. Advanced Obstetric Ultrasound / Date / Signature / Date / Signature / Date / Signature
Effective and safe use of imaging modalities
Optimise image for 2D ultrasound.
Optimise image for Doppler ultrasound.
Understand benefits of and indications for other imaging modalities, 3D, 4D, and MRI.
Uterine artery Doppler
Umbilical artery Doppler
Middle Cerebral artery Doppler, including vMax
Ductus Venosus Doppler
Cervical length
Ultrasound competency for the screening, diagnosis and management including timely referral of:
Severe early onset fetal growth restriction
Late onset fetal growth restriction
Twin pregnancy with growth discordance
Twin-twin transfusion syndrome
Suspected preterm ruptured membranes
Polyhydramnios
Low lying placenta
Ultrasound guided procedures:
ECV for Breech
Training Courses or sessions
Title
/Signature of educational supervisor
/ DateAuthorisation of signatures (to be completed by the clinical trainers)
Name of clinical trainer (please print) / Signature of clinical trainer
Completion of ASM 1: Advanced Obstetric Ultrasound
/ Date / SignatureComprising the safe and effective use of imaging modalities, the screening, diagnosis and management of the at risk fetus. Level 3 is to the level expected within Secondary Care and includes timely liaison with the MDT and Tertiary Centre when appropriate.
ASM 2 Confirming normality and management of key fetal conditions
Clinical competency /GMP
/Knowledge criteria
/ GMP / Professional skills and attitudes /GMP
/Training support
/Evidence/
assessment
(2.01) Demonstrate normal structural findings in all trimesters and recognise if normality cannot be demonstrated for:(2.02) Central nervous system
(2.03) Face and neck
(2.04) Thorax
(2.05) Cardiovascular system
(2.06) Abdominal wall and gastrointestinal tract
(2.07) Urogenital system
(2.08) Skeleton and extremities / 1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2 / (2.01-2.10)
Understand the embryology as listed below and how it is revealed in the ultrasound image.
(2.02)
Embryology of brain & spinal cord (incl. early postnatal development).
Recognise normal ultrasound appearance of: head shape, biometry, cavum, thalami, cortex, ventricles, choroid plexus, cerebellum, cisterna magna.
Measurement of: head circumference, lateral ventricle, transcerebellar diameter, cisterna magna, nuchal fold.
(2.03)
Embryology of: face and neck
Recognise normal ultrasound appearance of:head shape & biometry, lip, palate, neck, jaw.
Measurement of nuchal fold, Internal and external orbital distances.
(2.04)
Embryology of trachea, lungs, diaphragm & functional adaptations after birth.
Recognise normal ultrasound appearance of: chest size and shape -mediastinal shift, ribs, lung parenchyma, and diaphragm.
(2.05)
Embryology of: heart and cardiovascular system, understand circulatory adaptations at birth.
Recognise normal ultrasound appearance of:cardiac size, position and axis, atria & ventricles, outflow tracts, 3 vessels and trachea view.
Measurement of: heart rate, atrial and /ventricular rates.
(2.06)
Embryology of:Abdominal wall, and gastrointestinal tract.
Recognise normal ultrasound appearance of:abdomen, abdominal wall / cord insertion, stomach, small & large bowel, liver, gallbladder, intrahepatic vein & ductus venosus.
Measurement of: abdominal circumference.
(2.07)
Embryology of:genitor-urinary system (incl. physiology of fetal urinary system), functional adaptations after birth.
Recognise normal ultrasound appearance of: renal size, renal parenchyma & collecting system ureters & bladder, external genitalia.
Measurement of, liquor volume
(2.08)
Embryology of: normal skeletal system including spin and cranial vault.
Recognise normal ultrasound appearance of: bone shape, echogenicity (mineralisation), joint position, movements, tone. Identify digits.
Measurement of long bones, foot length.
/ 1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2 / (2.01-2.08)
Understand the strengths and limitations of ultrasound for each system within each trimester.
Ability to perform and record appropriately a detailed, systematic ultrasound assessment of each system for the entire fetus.
Explain normal anatomy views to patient.
Document and record normal anatomy views.
Understand local protocol for follow up if any after an incomplete anatomy scan. / 1,2
1,2
1,2,3,4
1,2
1,2 / (2.01-2.08)
STRATOG Advanced, Clinical Case Studies eLearning: Fetal Medicine – major congenital anomaly (2015).
National Screening Committee publications on normality at the 18-20 week scan.
Direct supervision from sonographers and senior clinicians / (2.01-2.10)
For the first part of this ASM focus on the normal anatomy so that variations from normal can be identified.
For this you need to provide evidence of regular ultrasound hands on sessions accompanied by work-placed based assessments as competencies are achieved.
(2.11-2.13)
Evidence of attendance at genetics clinic and laboratory testing.
(2.14-2.25)
You need to supply evidence showing a full understanding based on direct clinical care for these core fetal medicine anomalies.
Evidence of attendance at fetal medicine clinics with involvement of paediatric surgeons, neurologists, nephrologists and neonatologists.
Their screening is part of the NSC committee standards for the 18-20week scan.
(2.05-2.21) OSATS of Fetal Echocardiography
(2.09) Umbilical artery, middle cerebral artery, and ductus venous Doppler waveforms.
(2.10) Determine amnionicity and chorionicity / 1,2
1,2 / (2.09)
Understand the physiological basis for each Doppler waveform both normal and abnormal. Understand when they should be examined and their implications if abnormal.
(2.10)
Embryology of: monozygotic & dizygotic twinning, placentation, chorionicity / amnionicity.
Recognition of: T-sign and the lambda sign for chorionicity. / 1,2
1,2
1,2 / (2.09)
Explain and document normal findings in a way that can be easily understood.
(2.10) arrange appropriate pregnancy surveillance once chorionicity and amnionicity determined.
(2.20)
Explain finding in a way that can be easily understood. Describe how findings influence subsequent antenatal management. / 1,2,3,4
1,2
1,2,3,4 / (2.10) NICE CG:129 (2011) Multiple pregnancy: antenatal care for twin and triplet pregnancies.
Management of the key fetal anomalies
(2.11) Suspected and confirmed Trisomy 21
(2.12) Suspected and confirmed Trisomy 18 / Trisomy 13
(2.13) Suspected and confirmed Turner’s syndrome / 1,2
1,2
1,2
1,2 / (2.12-2.14)
Understand the genetic basis for trisomy 21, 18 and 13. Recognise the ultrasound features associated with screening for the common trisomies.
Understand the organisation & role of Clinical Genetics Services in the diagnosis of trisomies including invasive and non-invasive testing.
Understand any implications for the current pregnancy and the long term prognosis for each condition with any implications for future pregnancies. / 1,2
1,2
1,2 / (2.12-2.14)
Take an appropriate history and construct, where appropriate, a family tree in patients with or at risk of genetic disease.
Recommend genetic testing appropriately.
Reflection upon the ethical & societal issues of antenatal diagnosis.
Be able to give information in a non-judgemental way that is easy to understand.
Liaise appropriately with the Tertiary centre and MDT. / (2.12-2.14)
NSC publications and parent information leaflets.
RCOG Scientific impact paper No.15 (2014) Non-invasive prenatal testing for chromosomal abnormality using maternal plasma DNA.
(2.14) Anencephaly
(2.15) Spina bifida
(2.16) Renal agenesis
(2.17) Facial cleft
(2.18) Exomphalos
(2.19) Gastroschisis
(2.20) Diaphragmatic hernia
(2.21) Hypoplastic left or right heart
(2.22) Lethal skeletal dysplasia / 1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2 / (2.14-2.22)
Recognise diagnostic features of each condition their differential diagnosis and risk of associated structural, chromosomal and syndromic associations.
Understand antenatal management, intrapartum care and immediate postnatal management of each condition.
Be able to state when tertiary referral opinion is required, when and where delivery is recommended and the most appropriate mode of delivery based on the condition and individual’s circumstances.
For each condition, understand the recurrence risk and management plan for future pregnancies.
(2.15)
Spina bifida, Understand surgical options, long term prognosis. Be able to accurately identify the features of open and closed spina bifida.
(2.16)
Renal agenesis, understand antenatal and neonatal implications for both unilateral and bilateral renal agenesis.
(2.17)
Understand limitations of ultrasound for cleft palate. Understand role of 2D and 3D ultrasound. Be able to distinguish between unilateral, bilateral and midline cleft lip.
(2.18)
Exomphalos, identify size and contents and implications of each.Understand local monitoring policy and when to seek advice from tertiary centre.
(2.19)
Gastroschisis, understand local monitoring policy and when to seek advice from tertiary centre.
(2.20)
Diaphragmatic hernia: understand local pathway following identification of diaphragmatic hernia, role of MRI options for antenatal treatment.
(2.21)
Understand implications of a univentricular heart, staged operative palliation and long-term outcomes. Understand local pathway of care and antenatal surveillance.
(2.22)
Be able to accurately describe the skeletal anomaly.
Understand the common forms of skeletal dysplasia their most recognisable features and why some forms are lethal. (Including thanatophoric dysplasia, achondrogenesis, osetogenesis imperfect type II, campomelic dysplasia.) / 1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2
1,2 / (2.14-2.22)
Liaise with fetal medicine specialist, neonatologists, surgeons (including appropriate referral for second opinion).
In collaboration with specialists, formulate, implement and where appropriate modify management plan.
Counsel women and their partners regarding the fetal risks, long term outcome, postnatal or post mortem findings and the recurrence risks.
Support parent(s) using shared decision making.
Provide appropriate support and follow up of ongoing pregnancy.
Plan delivery and appropriate neonatal support in collaboration with fetal medicine specialist
Be able to give information in a non-judgemental way that is easy to understand.
Understand whether the option of termination of pregnancy is appropriate for each condition both in isolation and in combination with other anomalies.
Liaise appropriately with the Tertiary centre and MDT.
Formulate management plan for future pregnancy in collaboration with specialists / 1,2,3
1,2,3
1,2,3,4
1,2,3,4
1,2,3,4
1,2,3
1,2,3,4
1,2
1,2,3
1,2,3 / (2.14-2.22)
NSC publications and parent information leaflets.
Direct supervision from sonographers and senior clinicians including fetal medicine subspecialists.
(2.16)
Observation of Paediatric neurosurgical counselling.
(2.17)
Observation of paediatric nephrologist counselling.
(2.17)
Cleft liaison team where available,
CLAPA website.
(2.18-2.19)
GEEPS website.
(2.20)
MBRRACE-UK (2014) Perinatal confidential enquiry - diaphragmatic hernia.
(2.21)
Observe paediatric cardiologist counselling
Little heart matters, British Heart Foundation (BHF) websites.
(2.22)
Counselling of clinical geneticists.
OMIM: Online Mendelian inheritance in man.
Ultrasound guided procedures:
(2.23) Observe amniocentesis
(2.24) Observe chorionic villus biopsy.
(2.25) Observe feticide / 1,2
1,2
1,2 / (2.23-2.24)
Understand when it is appropriate to offer invasive testing.
Understand the contraindications to invasive testing.
Understand the role of non-invasive testing.
(2.26) Understand the legal framework under which termination of pregnancy by feticide may be offered. / 1,2
1,2
1,2
1,2 / (2.23-2.24)
Be able to explain the risks of each procedure and any alternatives.
Be aware of how the sample is processed, when and how the result is given. / 1,2,3,4
1,2,3,4 / (2.23-2.25)
Antenatal Results and Choices (ARC)
(2.25)
Abortion Act (1967) / (2.25)
This may be achieved to level 1 under other methodologies
ASM 2 Confirming Normality and Management of Fetal Anomaly Screening Programme (FASP) Conditions. / Part of the Fetal Medicine ATSM
Logbook / Competence level Not required
Level 1 / Level 2 / Level 3
ASM 2. Confirming normality and management of (FASP) Conditions.
/ Date / Signature / Date / Signature / Date / SignatureDemonstrate normal structural findings in all trimesters and recognise if normality cannot be demonstrated for:
Central nervous system
Face and neck
Thorax
Cardiovascular system
Abdominal wall and gastrointestinal tract
Urogenital system
Skeleton and extremities
Umbilical artery, middle cerebral artery, and ductus venous Doppler waveforms.
Determine amnionicity and chorionicity
Management of the key fetal anomalies
Suspected and confirmed Trisomy 21
Suspected and confirmed Trisomy 18 / Trisomy 13
Suspected and confirmed Turner’s syndrome
Anencephaly
Spina bifida
Renal agenesis
Facial cleft
Exomphalos
Gastroschisis
Diaphragmatic hernia
Hypoplastic left or right heart
Lethal skeletal dysplasia
Ultrasound guided procedures:
Observe amniocentesis
Observe chorionic villus biopsy
Observe feticide
Training Courses or sessions
Title
/Signature of educational supervisor
/ DateAuthorisation of signatures (to be completed by the clinical trainers)
Name of clinical trainer (please print) / Signature of clinical trainer
Completion of ASM 2: Confirming normality and management of key fetal conditions