Midwifery Use of Ultrasound: A Review of Standard Setting Documents
Kristen M. Ostrem-Niemcewicz CNM, FNP-BC, DNP, FACNM
Chair, ACNM Ultrasound Education Subcommittee
Midwives have been using ultrasound to enhance their clinical toolkits for decades. This tool was recognized by the American College of Nurse-Midwives (ACNM) over thirty years ago when the first position statement addressing midwifery use of ultrasound was published. Since then, ACNM has updated its Position Statement (PS) to reflect the evolving use of ultrasound in midwifery practice. The ACNM PS, Ultrasound in Midwifery Practice (2018) was updated in the spring of 2023 with input from the ACNM Ultrasound Education Subcommittee and the Division of Standards of Practice. The Board of Directors approved the updated version available on the midwife.org website. The 2023 document can be accessed by clicking the Learn tab, then the Professional Resources tab, position statements are housed in the ACNM Library found on the right side of the webpage.
One of the updated references to our professional organization's Position Statement is a new Training Guideline published by the American Institute of Ultrasound in Medicine (AIUM). This training guideline titled, Training Guidelines for Licensed Medical Providers (PA, NP, CNM/CM, DPT, and DC) Who Perform and/or Interpret Diagnostic Ultrasound Examinations, was created for practices that are pursuing AIUM accreditation. The ACNM Ultrasound Education Subcommittee had input on the new document with the goal of maintaining midwifery's scope of practice, our position statement, and recognition of the optional American Registry of Diagnostic Medical Sonographers (ARDMS) Midwife Sonography certificate.
These national documents are important for all midwives to read and reference when creating a clinical practice guideline that describes their expansion of practice to include ultrasound for clinical decision-making. Another key national document is the ACNM (2022) Position Statement, Expansion of Midwifery Practice and Skills Beyond Basic Core Competencies. The document replaces our reference to ACNM Standard of Practice, VIII. It provides a step-by-step guide for midwives to create CPGs for care that was not included in the basic midwifery education program. The midwife can create a CPG based on answering questions organized in five domains. The first domain, knowledge, prompts the midwife to document the expansion of knowledge. Accessing ultrasound knowledge and skills are addressed in the ACNM (2023) Ultrasound in Midwifery Practice PS and the AIUM Training Guidelines. The expertise should be grounded and consistent with state, licensure, and institutional regulations. The second domain, role validation, prompts the midwife to describe their role preparation and definition while recognizing state and professional organizations. The midwife’s expanded education and new scope should be publicly accessible. The third domain, competence, and skill, prompts the midwife to document the achievement of clinical competencies and maintenance of the expanded skill. Those clinical competencies should be compared to a practitioner in the field with evidence of meeting the same standard. The fourth domain, environment, prompts the midwife to document a workplace survey addressing support of the expanded skill and the provision of liability coverage. The skill should facilitate and not delay access to the same care by the best-trained individual. For example, if a midwife is re-evaluating fetal growth following an ultrasound finding of fetal growth restriction, limiting documentation to biometry would not meet the standard of care. Follow-up fetal growth evaluation should include amniotic fluid and umbilical artery Doppler evaluation (ACOG, 2021; Williams et al., 2018). Without those components, a midwife would refer the assessment to a qualified provider. Importantly, umbilical artery Doppler assessment is not included in the content outline for midwifery ultrasound certification (ARDMS, n.d) or in the ultrasound obstetric exam as described in the AIUM Practice Parameter for the Performance of Limited Obstetric Ultrasound Examinations by Advanced Clinical Providers (2018) co-authored by ACNM and other advanced practice provider organizations. Adding Doppler or other assessments would require additional education and hands-on training that can be added if appropriate to the midwife’s ultrasound CPG. The fifth and final domain, ethics, prompts the midwife to document potential consequences and management of those consequences that may be associated with adding the skill. Management includes listing consultation resources, ensuring informed consent by clients, and sharing documentation of the care and assessment with a primary care provider (PCP) if the midwife is not serving as the PCP.
In conclusion, midwives are well supported by their professional organizations to expand their knowledge and skills. Sharing clinical practice guidelines is an important step in disseminating the extension of midwifery practice. For further support or information, please contact the ACNM Ultrasound Education Subcommittee at [email protected]. We will put you in touch with subcommittee members within or near your region.
American College of Nurse-Midwives. Standards for the practice of midwifery. 2022. Accessed August 29, 2023.https://www.midwife.org/acnm/files/acnmlibrarydata/uploadfilename/000000000051/2022_standards-for-the-practice-of-midwifery.pdf.
American College of Nurse-Midwives. ACNM position statement: Expansion of midwifery practice and skills beyond basic core competencies. Revised June 2015. Accessed August 29, 2023. http://www.midwife.org/acnm/files/ACNMLibraryData/UPLOADFILENAME/000000000066/Expansion-of-Midwifery-Practice-June-2015.pdf
American College of Nurse-Midwives. ACNM position statement: Ultrasound in midwifery practice. Revised 2023. Accessed October 24, 2023. https://www.midwife.org/acnm/files/acnmlibrarydata/uploadfilename/000000000318/2023-ps_ultrasound-in-midwifery_practice.pdf
American College of Obstetricians and Gynecologists. (2021). Fetal Growth Restriction: ACOG Practice Bulletin, Number 227. Obstet Gynecol. 137(2):e16-e28. doi:10.1097/AOG.0000000000004251
American Institute of Ultrasound in Medicine. AIUM practice parameter for the performance of limited obstetric ultrasound examinations by advanced clinical providers. J Ultrasound Med. 2018;37(7):1587-1596. doi:10.1002/jum.14677
American Institute of Ultrasound in Medicine. Training Guidelines for Licensed Medical Providers (PA, NP, CNM/CM, DPT, and DC) Who Perform and/or Interpret Diagnostic Ultrasound Examinations. March 10, 2023. Accessed August 29, 2023. https://www.aium.org/resources/training-guidelines/view/training-guidelines-for-licensed-medical-providers-(pa-np-nmw-dpt-and-dc)-who-evaluate-and-interpret-diagnostic-ultrasound-examinations
American Registry of Diagnostic Medical Sonography. Midwife sonography certificate. Accessed August 29, 2023. https://www.ardms.org/get-certified/midwifery
Williams, M., Turner, S., Butler, E., & Gardosi, J. (2018). Fetal growth surveillance–Current guidelines, practices, and challenges. Ultrasound, 26(2), 69-79.