Empowered Pregnancy Education - The 20 Week Anatomy Scan

By: Aunt Doula (11/28/2023)

Welcome, and congratulations on reaching the milestone of the 20 week anatomy scan. This can be a scan filled with anything from anxiety to joy or a mixture of several emotions for many people, so if you are having difficulty with what to expect, have questions that aren't answered here or have a history of receiving news of potential problems please know you can reach out directly to me to talk.

Purpose of the Scan

The purpose of the 20 week scan is to look for any abnormalities in your baby, however the grand majority of these scans are to rule out problems and confirm a healthy baby, not rule in any issues - meaning that your scan has a much higher likelihood to be a great time to see your little one, get some photos and hear their heartbeat. It is where I encourage people to try and center their thoughts around and if they are worried, to always return to this thought as often as possible.

At 20 weeks, the fetal body has primarily developed all body systems to a solid base level that can be evaluated for function, size, or abnormalities. It is a standard time by which broad comparison can be made through averages because nearly all monitored pregnancies are scanned at this same gestation.Anytime there has been a history of problems found at a scan, a history of loss or diagnosis that complicates a pregnancy/birth/life it can increase the anxiety leading up another in a subsequent pregnancy. It is also very common to not be able to remember clearly what happened during an exam that went sideways, so whether this is your first 20 weeks scan or a subsequent pregnancy 20 week scan, below you will find an overview of the broad process and questions you can ask to get the most out of your scan and reduce your anxiety before hand as much as possible.

Why 20 weeks?

The anatomy scan (sometimes called a level 2 scan) is done at 20 weeks because it is the gestational period when everything in growth and development is as close to equal proportion as it will be so measurements are easier to compare across the entire body. This allows for a very strong predictive model to ensure your baby is on track and healthy. A week on either side is still very predictive, and still tells doctors what they need to know. Sometimes, you may need to return for a second scan if some images weren't able to be obtained. This does not mean anything is wrong! Babies are notorious for knowing the camera is on, and they act like either the shy and hiding type, or they move so much everything is a blur - this is a common thing to have happen and does not mean they suspect something is wrong - it's usually just a need for baby to be in a different position and it wasn't happening that day.

By 20 weeks, the ultrasound can almost always be *transabdominal* meaning the ultrasound wand will be on top of your belly. Rarely, you may need a transvaginal ultrasound in addition to the transabdominal ultrasound. This includes a wand that is inserted into your vagina to obtain pictures of your cervix, placenta, or even baby. This is usually not required by 20 weeks, but if you have never had one or never knew it was a potential part to the exam that could happen it can be a bit of a shocking surprise. I add it here so you can be prepared, not scared. The need to have a transvaginal exam are increased if you have a higher BMI, known cervix issues that warrant a closer look to ensure things are well, or if your placenta is in a lower position and further images are needed. This list is not exhaustive, but the important thing to take away from this is that it may happen, and you absolutely can refuse it if you aren't ready or want to come back another day to try abdominally again before doing a transvaginal scan. As with any procedure - you hold the reins. You do not have to consent to a surprise procedure change, especially one that could be traumatic or painful and you need time to be ready physically and emotionally.

The Process Overview / What to Expect

Most scans begin with you laying on your back in a semi reclined position. You may be asked to change into a gown, or you may be allowed to just pull your shirt up and slide down your pants below your hips. Your modesty should be protected to your comfort level, so if they don't offer you what makes you feel at ease, ask if there is another option. Once they have you comfortable, they will apply warmed (hopefully!) jelly lubricant to your belly. This allows the wand to move smoothly and give the best images by making it possible to make small adjustments without friction.

This is when the measuring and images appearing on the screen will begin, and in most centers who do 20 week scans regularly, there will be a separate screen so you can see the scan as it happens. Facility to facility, country to country, ultrasonographer to ultrasonographer - your experience may vary. This means the order they take measurements, when they take pictures for you to bring home, how much they narrate where they are scanning as they go, and if they point out structures or not. I highly recommend calling ahead or asking when you schedule what the policies are around what the sonographers are allowed to disclose, if they can point out structures, how many pictures they can give, and if you need to have a full bladder when you get there! (This will be in the questions section below as well)

Many things will be coming across the screen throughout the scan, and there will be measurements that look like lines being pulled from one point to another, there will be moments you see flashing red and blue blotches (this is blood flow), areas that look black, grey, splotched or white, and even some parts of the heart movement are visible when they are taking those images. However in general much of it won't necessarily be recognizable as it is zoomed in on particular areas of the body for the medical purpose of the 20 weeks scan which is to make sure everything is on track. Each sonographer is different in their process, so they may show you the profile of your baby (be able to see them from head to toe) or baby's face along with take memory photos before getting all the measurements. Some wait until after. You can ask if you want to know so you don't worry it might not happen. You can also ask for specific pictures (this may or may not be accommodated or possible) or if you can have some extras. This is all very facility dependent and nothing is guaranteed until the day you get there, but asking ahead will help you have a better expectation of what you are most likely to receive.

If at anytime your sonographer has to excuse themselves, don't panic! Some sonographers have more experience than another and it may be that your sonographer wants help from another to save you a second trip if possible, or they need to get a second opinion on a measurement that isn't quite adding up and may be equipment related. While there is a possibility that they may have seen something concerning, they aren't really allowed to say so to you as they aren't your doctor. They may be going to get a doctor to come and scan right then if there is something - the point is, answers are coming back with your sonographer, the sooner you let them go get whoever they need to get, the sooner they will be back and be able to tell you more. This can feel like a long and arduous wait, but to the best of your ability, take a deep breath and assume the best.

Some scans are 30 minutes long, some are 90 minutes long some are in between - all can lead to a normal and healthy baby report. The length of the scan rarely determines if there are issues, it usually just indicates how shy or rambunctious baby is, giving the sonographer a run for their money!

Things to Know or Keep in Mind

While sonographers are not allowed to diagnose a problem, in most facilities they are allowed to narrate what they are doing while they are doing it. So while they cannot say if they see an issue or a measurement is off, they can tell you that they are measuring the leg, or looking at the blood flow of the heart. You may get a sonographer who isn't a talker/narrator - they may not turn on the screen for you even if there is an extra, or not be willing to position things so you can see their screen - if you get this kind of sonographer, you can politely ask if they could say what they are doing or what area of the body they are scanning so you aren't just laying there in the quite darkened room with anxiety and not being able to be involved at all. This is not at all the kind of 20 week scan experience people talk about or usually want, so if things are going that way - speak up! You do get to ask what going on in general, you do get to ask if you can watch any sort of way, and this is your body and baby during a scan that traditionally IS narrated and involves you.

Sometimes, sonographers float between facilities and while they are trained and capable to perform your 20 week scan, they may not always be doing them and therefore don't have a routine or bedside rapport for pregnancy scans. Again, you deserve to enjoy your scan - if your sonographer is keeping you from things you are entitled to have it is your right to ask for another sonographer! It can be hard to imagine asking for it, but by reading this and by calling ahead, you reduce the risk of this happening. Down in the questions section this looks like "Do all of your sonographers focus on pregnancy scans and amenities like photos, hearing the heart beat and naming structures as they go through the scan? Is there a way to schedule with a sonographer who does focus more on pregnancy scans?"

As you near your 20 weeks scan, your provider may have an appointment the same day with you but the results may not be ready. When you have an ultrasound that isn't done by your doctor or in their office directly with a radiologist on staff, all of the measurements and the interpretation, calculations and complete report may not be ready as soon as you arrive at your appointment. This can be a big letdown if you scheduled same day for your provider but the report isn't available, so as you'll see in the questions section, this is there because of that extra step in this process.

Findings

In the unlikely event that something does appear concerning on your scan, know that this scan is a *screening* exam. Screening means that it is there to tell your doctor if they need to look deeper at anything. If something is found, do your very best to stay present, but also be ready to forget just about everything that they say in that appointment once you leave. When we hear news that has the potential to change our entire lives, we have a protective mechanism in our brains that basically short circuits short term memory and prevents us from remembering the scary things we heard/experienced. This can be strange, frustrating and downright unhelpful, but know that it is very normal to not remember clearly what was said and what you need to do next. In this unlikely event that there is something found, write down key words or ask your doctor to write down key words and to write what the next 2 major steps are going to be (appointment with a specialist, or a repeat scan, for example) If your providers office has an online portal with visit summaries it can be a place to go for finding out next steps later as well but sometimes this can be too much information without enough context in the early hours and days of limbo, so I encourage writing things down that you hear directly from your doctor/their office until you have had the time to digest and have a more even keel.

Questions to ask the ultrasound facility

- Do you have sonographers who focus primarily on pregnancy & 20 weeks scans?- Do you have sonographers who are trauma informed and can handle anxious patients?

- Do you provide photos of baby, and if so how many?

- Can I request a certain photo position of baby?

- Do I need to have a full bladder when I arrive?

- Do you have a doctor on staff that can check potential abnormality findings during the scan?

- How long do reports take to be read and sent to my provider on average?

- Should I bring a cold or sugary beverage or do you provide options if baby needs encouragement to change position?

- Do you have a separate screen in each room for viewing our scan as it is happening?

- Can I record the sound of the baby's heartbeat on my phone?

- How much are sonographers allowed to narrate the progression of the scan such as pointing out structures like the heart, hands, toes? Are they allowed to say what structure they are measuring as they go along to keep us involved?

- If I need an extended scan or additional transvaginal scan, does that usually get worked in at that appointment or would I need to plan to come back?

- Can I request a female sonographer?

All of these may apply to you, you may only be wondering a few, or there may be some that you think of not on this list. While not exhaustive, it is designed to get you thinking about things that you might not have realized were something causing you anxiety. Be open to not hearing the answer you want, and recognize that by asking now, you know before you go and this means you may be able to schedule with a different center or ask if there are any accomodations that could meet in the middle. The 20 week scan is a detailed exam and it is a medical process taking important focus from your sonographer to complete - however - this is also a time for you to see and hear your baby which is a very powerful moment for many, many people. If you don't feel like you will be receiving the atmosphere or support and accomodations you need from a center, look into your options and ask them the questions too. Sometimes, we don't have a choice in where to go, and if that is where you are, at the very least you can adjust your expectations and not be coming on with an unrealistic bar of what you will be receiving. While this wouldn't be ideal, it does blunt the disappointment a small amount.

Take Away

The grand majority of 20 week scans not only are resoundingly normal, they are also an enjoyable and memorable time to see and hear baby. Again all of this information and staying one step ahead is to *prepare you - not scare you* so to the best of your ability, assume the best, set yourself up for the enjoyable and memorable moments, and take it one step at a time.