CHAPTER III THE SIGNS OF PREGNANCY
Tue diagnosis, or the establishing of the fact that pregnancy exists, belongs to the physician; to the nurse falls the duty of interpreting the impor- tance of certain signs arising from pregnancy. She may have no other responsibility than to make herself familiar with them, as standards by which abnormal conditions may be judged. At the same time she should be able to understand them. The signs of pregnancy are those evidences which are apparent not only to the woman herself, but to the observer also. The symptoms of pregnancy are those indications which the woman herself is conscious of. We may consider all the evidences of pregnancy, including the symptoms, under three headings:
Doubtful signs.
Probable signs.
Positive signs. “
Doubtful Signs.—The doubtful signs are those evidences which may occur not only in pregnancy, but in other conditions as well. The most impor- tant of these, because it is the first that makes itself known to the patient herself, is the stopping of her monthly period. In a healthy woman with whom menstruation has been regular this is important. There are two things to be noted, however; first, that menstruation may be either deferred or its absence may be due to some condi- tion which has not shown itself in any other way; second, a discharge similar to menstruation may occur during pregnancy.
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Together with this sign, because it occurs next in sequence, we may mention the symp- tom of nausea. This occurs after the end of the first month and continues for 6 or 8 weeks. It is sometimes a recurring symptom, appearing periodically or toward the end of pregnancy, and is called, from the time of its daily appearance, morning sickness. It is usually accompanied by vomiting. It is grouped with the doubtful signs of pregnancy, as it may be due to other causes. Pregnancy may even exist without its being present atall. +
The sign of next importance is abdominal en- largement. From the end of the third month this may be detected. The mistaking the uterine enlargement for any other condition may be pre- vented by remembering that the uterus occupies a position in the middle line of the body and that it is symmetric in shape. Although the enlargement of the uterus is only a doubtful sign, when con- sidered together, however, with morning sickness and the cessation of the monthly period it indicates pregnancy. An irritable condition of the bladder which causes the patient to void urine frequently is sometimes included among the doubtful signs of pregnancy.
Among the doubtful signs is the craving for unnatural articles of food. Mental depression and emotional disturbances may also point indefinitely to beginning pregnancy.
Probable Signs.—Among the important prob- able signs are the changes which occur, in the breasts. Before the end of the second month the woman is aware of a sense of fulness, such as precedes menstruation in some women. In fact the similarity to the latter sensation makes this an uncertain sign. Slight enlargement is also noticed. Later the changes consist, first, in a distinct enlargement with an underlying nodular hardness;
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THE SIGNS OF PREGNANCY 23,
second, in the deepening in color of the area about the nipple. This is not conspicuous in blond women, while in brunettes it forms a wide circle, deeply pigmented. At the outer edge of this circle may be seen a mottled area where the pigmentation or deepening color blends with the color of the surrounding skin, so that little islets of unpig- mented skin appear evenly distributed in the discolored area. They are called the glands of Montgomery. The pigmentation about the nipple iscalled the areola. The outer, partially pigmented area, including the glands of Montgomery, is called the secondary areola.
Fic, 8.—Changes in the breasts significant of pregnancy (after Hirst).
The nipple may remain unaffected by pregnancy, although where it is at all prominent it may increase somewhat in size. A slight, yellowish discharge exudes from the nipple, called colostrum. It is apt to dry in a delicate crust if not removed.
In women who have recently nursed an infant the appearance of a discharge from the nipples may serve as an indefinite sign of pregnancy. The remnant of milk in the breast will exude and will resemble colostrum. It is important, however, to note that the colostrum is much thinner than the milk which is left in the breast, and much more apt to dry into a crust. In women of fair skin the network of superficial veins may be more or less plainly seen in irregular blue lines which traverse the breast.
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A similar discoloration occurs in the mid-line of the abdominal wall. This begins in the lower portion and extends upward to a point corre- sponding to the height of the fundus. In women of dark complexion the whole of the abdominal wall, including especially the area about the navel, is apt to become pigmented.
In the skin of the breasts and abdomen, some- times over the front of the hips, there appear
Fic. 9.—Distribution of abdominal strize.
bluish or pinkish glazed lines called strie (Fig. 9). They are not altogether distinctive of pregnancy when they appear over the abdomen, but they rarely occur upon the breasts in other conditions. They are due to tearing apart of the deeper layer of the skin from stretching. They are in reality small scars. In women who have already gone through pregnancy they are glistening white in appear- ance. On the abdomen they are usually ar- ranged vertically, with an outward curve, corre- sponding to the shape of the uterine enlargement. They are classed among the probable signs because
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they may occur in other conditions, while, on the other hand, they may be absent in some women during pregnancy.
Although the early abdominal swelling is doubtful, yet the steadily increasing enlargement is a more positive evidence of pregnancy, and should be classed among the probable signs.
There are other probable signs which may be merely mentioned here, as they have to do with the question of diagnosis alone. They are in part revealed by internal examination. They are the changes in the cervix or neck of the womb, the consistency and shape of the uterus, the violet discoloration of the mucous membrane of the vagina, and, finally, the sense of fluctuation expe- rienced by suddenly displacing the fetus in tapping the uterus, called ballottement. After the middle of pregnancy two signs which are also medical, inasmuch as they require trained observation for their detection, occur. They are the wlerine souffle or blowing sound heard over the uterine artery, corresponding to the mother’s pulse beat, and the rhythmic contraction of the womb. The latter is spoken of as the Braxton Hicks sign. The Braxton Hicks sign occurs at more or less lengthy periods, the contraction lasting for a few seconds to a half minute. The contractions are painless at first, but as pregnancy advances they become noticeable on account of the bearing-down sen- sation which they produce. It is this latter tendency that makes the uterine contractions important for the nurse to observe, as the increase in pain denotes irritability of the uterus, usually the result of fatigue. Very often contraction pains are relieved by rest.
Positive Signs.—The first of these is com- prised in what are called the active movements of the fetus. They are to be recognized after the fifth month. The fetus within the uterus moves
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with its body, as a whole, by the sudden extension of the back, which is bent to accommodate its cramped position, and with its extremities. These movements constitute an unmistakable sign of pregnancy, although when they first occur the woman herself may mistake them for the dis- placement of gas in the intestines. This is especially the case in primiparous women who have not gone through the experience of pregnancy. After the sixth month the movements may be detected by sight and by placing the hand over the abdominal wall in palpation.
The first sensation of the fetal movement is called quickening. It occurs in primiparous women any time after the middle of pregnancy or the end of the twentieth week; in multiparous women from two to three weeks earlier than this. The first sensation recognizable is that of a slight fluttering. This is at first momentary and dis- appears, to return again more decidedly.
The second positive sign is to be found in the fetal heart sounds. It is most important for the nurse to be able to recognize these, as she might at any time be left in charge of the patient in labor, where the condition of the fetal heart would indi- cate the necessity of taking urgent action to save the child. Here it would be the nurse’s duty to call for the physician. Her ability to recognize the variations in the heart sounds would be of help in informing her when she should send for him. The fetal heart sounds are heard through the abdom- inal wall, usually at a point where the child’s back presses against it; they resemble the muffled tick- ing of a watch, except that the beat is double. Their frequence is 144 to the minute, much more frequent, therefore, than the mother’s pulse, which may be recognized in the pulsation of the large artery of the body (the aorta), or in the rushing sound of the uterine souffle. In listening for them the woman
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should be placed upon her back with her knees un- bent. The clothing should be pushed away from the abdomen and the latter covered by a smooth towel. The nurse should place herself usually on the left side, as the heart beats are more frequently heard on this side, with her back toward the patient’s head. This insures less constraint in the nurse’s attitude as she bends over the woman. Some- times it is better to turn the patient toward one or the other side, in order to bring the surface of the child over which the heart beats are to be
Fic. 10.—Position for nurse to assume in listening to fetal heart sounds.
heard toward the mother’s abdomen. The fre- quency of the fetal heart beats may be estimated by counting for one-twelfth of a minute; that is, for one-half the space marked between the numbers on the second dial of a watch. There should be twelve beats in this space of time, or 144 beats to the minute. If during labor this number is decreased to less than 100 in the interval between pains, or increased beyond 190, there is urgent necessity for interference, and the condition should be reported to the physician.
It will be noticed that the positive signs, the fetal movements and fetal heart sounds, occur late in pregnancy. In the early period the only way
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we may be able to be positive of pregnancy is by studying the signs in combination. Whena woman complains, for instance, of absence of menstruation, morning sickness, and abdominal distention we may say, from the grouping of these signs, that in all probability pregnancy exists.
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