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Course: Maternity Nursing

Topic: Diagnosis of Pregnancy

The Nurses International Community

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Module Goals

The learner will be able to:

List possible signs of pregnancy
List diagnostic signs of pregnancy
Describe and apply GTPAL system
Calculate Estimated Due Date (EDD) and gestational age

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Why is Diagnosing Pregnancy Accurately Important?

First and second trimesters of pregnancy are the crucial stages of fetal development
Early diagnosis of pregnancy helps mother:

Make health and lifestyle decisions to promote healthy development of the fetus
Make decisions about unwanted pregnancies

Identify the accurate gestational age
Allow for early assessment and detection of risk factors

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Possible Signs/Symptoms of Pregnancy

Possible signs/symptoms of pregnancy are those that suggest pregnancy, but may be caused by something else
Possible signs/symptoms of pregnancy:

Cessation of monthly menstrual period
Nausea and vomiting
Fatigue
Frequent urination - Polyuria
Abdominal growth
Breast enlargement and tenderness

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Possible Signs/Symptoms of Pregnancy

Cessation of menses

Often the first sign of pregnancy
Other possible causes are poor nutrition, emotional troubles, or menopause (change of life)

Nausea and vomiting

Hormone changes during pregnancy cause nausea in the morning- also called morning sickness
Some women may experience nausea throughout the day
Other possible causes of nausea and vomiting are illnesses such as food poisoning or parasites

(Klein et al., 2020a)

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Possible Signs/Symptoms of Pregnancy

Fatigue

Feeling very tired for first 3-4 months of pregnancy
Hormonal changes, especially Progesterone causes fatigue
Other possible causes are: anemia, poor nutrition, emotional concerns, over exertion

Polyuria (frequent urination)

Common during the first 3 months and in the last 1 or 2 months of pregnancy due to pressure of the uterus on the bladder
Other possible causes of dysuria are stress, bladder infection, or diabetes

(Klein et al., 2020a)

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The following contribute directly to pregnancy fatigue in the first trimester:During early pregnancy, hormonal changes are likely the cause of fatigue. Your body is producing more blood to carry nutrients to your growing baby. Your blood sugar levels and blood pressure are also lower. Hormones especially increased progesterone levels, are responsible for making you sleepy.

Hormone changes. The body sees increased production in estrogen, progesterone, prolactin, hCG, and hPL². These, along with other hormones and adjusting adrenal and thyroid levels, will all take a toll on energy levels.

Increased progesterone. Progesterone is needed for increased laxity in joints and ligaments, as well as for the growing uterus. However, increased progesterone can also cause sleepiness.

Lower blood sugar levels. Lower blood sugar levels, or hypoglycemia, can occur if not eating enough. As the fetus’s need for glucose grows, it’s important to keep blood sugar levels stable and calorie intake consistent. Hypoglycemia among pregnant women is most common in those with diabetes.

Lower blood pressure. Lower blood pressure, or hypotension, occurs as the circulatory system expands and hormonal changes contribute to the dilation of blood vessels resulting in feeling faint, dizzy, or lightheaded.

Lower iron levels. Much-needed iron is now also going to the fetus which can leave a pregnant woman feeling run down.

Faster pulse and breathing rate. Pregnancy causes more blood to circulate through the body and, with it, comes a faster heart rate.

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Possible Signs/Symptoms of Pregnancy

Abdominal growth

The uterus moves out of the pelvis after the 12th week of pregnancy and abdominal growth is noted
Other causes- abdominal mass or obesity

Breasts enlargement

Pregnant woman’s breasts enlarge due to hormonal changes in preparation for lactation
Breasts enlarge and may be tender

(Klein et al., 2020a)

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Case study:

A woman came into the clinic and expressed her concern to the nurse that she might be pregnant. She said she had been feeling exactly what her sister said she felt when she was pregnant. She had been having nausea and vomiting for a week and feels weak and tired. She said that she is sure that she is pregnant because she missed her monthly period 5 days ago.

Would the nurse diagnose pregnancy from the woman’s health history? Why?

What would the nurse do next?

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Positive Signs of Pregnancy

Positive signs of pregnancy are those that assessed by a healthcare provider and can only be attributed to the fetus:

Healthcare provider palpates fetal movement
Healthcare provider able to palpate fetal outline
Fetal heartbeat can be heard on a fetoscope, stethoscope, or seen on fetal monitor
Pregnancy test is positive
Ultrasound confirms pregnancy

(Klein et al., 2020a)

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Positive Signs of Pregnancy

Fetal movements

Healthcare provider can feel fetal movement at about 20 weeks pregnancy

Fetal outline

By 6th or 7th month, a skilled provider/midwife can palpate fetal head, neck, back, arms, bottom, and legs

(Klein et al., 2020a)

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Positive Signs of Pregnancy

Fetal heartbeat

By 5th or 6th month, fetal heartbeat can be heard with stethoscope or fetoscope
By 7th or 8th month, a skilled practitioner/midwife can usually hear the fetal heartbeat when listening with their ear placed on the woman’s abdomen

(Klein et al., 2020a)

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Positive Signs of Pregnancy

Laboratory results

Urine test :

Urine sample is used in the test kit
detects human chorionic gonadotropin hormone (hCG)
Test is positive after two weeks of conception

Blood test:

woman’s blood sample is drawn by health care worker
tested in lab for hCG to diagnose pregnancy
accurately predicts pregnancy by the second week after conception

(Stanford Children’s Health, n.d.)

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Case study:

A 28- year- old woman came in to the clinic and informed the nurse that she may have become pregnant after unprotected intercourse. She told the nurse that results of at-home pregnancy test that she did twice were negative, but she was was not sure if they were 100% accurate. She wants to know if she is pregnant.

Do two negative at-home pregnancy test results rule out pregnancy? why?

What should the nurse do to accurately identify pregnancy status of the woman?

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Do two negative at-home pregnancy test results rule out pregnancy? why?

A pregnant woman might have a negative result in an at-home pregnancy test if,

An at-home pregnancy test is performed before two weeks of unprotected sex or conception.
Instructions for the test are not followed accurately

What would the nurse do to accurately identify the pregnancy status of the woman?

The nurse would determine if the at-home pregnancy tests were done after two weeks of the day woman had unprotected sex.

If it is not so then, the nurse should ask the woman to repeat the pregnancy test as follows:

test after two weeks from the date of unprotected sex
test after one week from the day of the missed monthly period.

The clinic can offer a diagnostic blood test for pregnancy to be done after two weeks from the day of the unprotected sex.

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Extrauterine Pregnancy/Ectopic Pregnancy

Fertilized egg grows outside of the uterus, usually in the fallopian tube
If left untreated, the fallopian tube may rupture and may cause life threatening bleeding
Warning Sign/symptoms:

Initial light vaginal bleeding and pelvic pain
If blood leaks from fallopian tube - shoulder pain or urge to have bowel movement may occur
If tube ruptures- heavy bleeding inside abdomen leading to lightheadedness, fainting, and shock

(ACOG, 2018; Mayo Clinic, n.d.)

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GTPAL System

Used to summarize a woman’s obstetrical history
Terminologies:

Gravida: Number of pregnancies (including current one); Twins, triplets, and other multiple fetuses count as one pregnancy and one birth
Term: Number born (alive or stillborn) at 37 weeks gestation onward
Preterm: number born between 20-37 weeks (alive or stillborn)
Abortion: pregnancy loss before 20 weeks counts as a pregnancy
Living children: number of living children (twins/triplets count individually)

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Case study:

Esmeralda is pregnant with 3 living children. She has previously had 1 miscarriage. Her first child was born at 38 weeks, her second child was born at 40 weeks, her third child was born at 36 weeks after an induction due to pre-eclampsia.

What would the nurse record in GTPAL section of the Esmeralda obstetric history?

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Calculating Estimated Due Date (EDD)

Once pregnancy is established, EDD must be estimated as accurately as possible

Methods:

Based on last menstrual period (LMP)
Using Moon phases
Ultrasound fetal measurements
Using Naegele's rule

(Klein et al., 2020a)

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Calculating EDD- LMP

(Klein et al., 2020a)

Take first day of woman’s LMP and add 9 months and 1 week (7 days) to it

LMP method is reliable only if the answer to all of the following questions are ‘Yes’:

Has your monthly bleeding been regular, once every 4 weeks (once every month)
Was your last monthly bleeding normal for you (not unusually light or heavy)?
Do you remember the date of the first day of your last monthly bleeding?

My last monthly bleeding started May 6th. If I add 9 months, that comes to February 10th. Then I add 7 days, which tells me her baby should be born around February 17th.

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EDD Calculator Tool- Pregnancy Wheel

Smaller circle

Larger circle

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Calculating EDD- Using Moon Phases

Calculating EDD- Sonogram

If woman’s monthly bleeding (menstruation) is 1 moon apart (4 weeks) then, baby is due 10 moons after the first day of last monthly bleeding
If the monthly bleeding started on a quarter moon, the baby is due 10 quarter moons later
If woman’s bleeding started on a new moon, baby is due 10 new moons later

Sonogram or ultrasound machine uses sound waves to take a picture of the fetus
Sonograms done after 6 months of pregnancy are less accurate

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Case study:

Nina who is 12 weeks pregnant came for her first antenatal check up. Her chief complaint is nausea and vomiting. She tells the nurse that the first day of her last menstrual period was 3 May 2019.

How would the nurse calculate EDD? (use two of the methods described and compare results)

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Calculating Gestational Age

(Klein et al., 2020a)

Using Calendar: Take the first day of LMP and count number of weeks that have passed between that day and current visit

Using Sonogram machine: If done in first 6 months of pregnancy, gives more accurate gestational age

By the end of May

I had been pregnant for 4 weeks, and...

...by the

end of June,

8 weeks.

Today is July 12th, so I am 9 weeks and 4 days pregnant, or a little more than 2 months.

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Calculating Gestational Age

Bimanual exam:

Feel the uterus by bimanual approach
This exam can be done before 12 weeks (3 months) of pregnancy to feel the size and shape of the womb.
Usually uterus feels firm, smooth, and smaller than a lemon i.e 6cm to 10 cm
In pregnancy uterus is enlarged

(Klein et al., 2020a)

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According to Hesperian Health Guides ‘A Book for Midwives’: This procedure is performed based on the national and legal regulations and scope and practice of the nurse. These regulations vary nationally and internationally.

Steps for bimanual exam:

1. Wash hands and wear very clean or sterile gloves.

2. Have the woman lie on her back with a pillow under her head.

3. Explain everything about the bimanual exam procedure to the woman

4. Remind her to relax during the exam and stop the exam if she is in pain

5. When she is ready, put lubricating jelly on the first 2 fingers of your hand that you will be inserting inside the vagina.

6. Gently pen the lips of her genitals with lubricated fingers, ask the woman to take a deep breath to help her relax, then with palm facing up gently put the fingers all the way into the woman’s vagina

7. Feel the cervix which should be firm, round, and smooth.

8. If you cannot feel the cervix ask the woman to cough or push down as if she were passing stool until the cervix touches your fingers.

9. Put your other free hand on the woman’s abdomen, below her navel (bellybutton) and above the hair around her genitals.

10.Feel the uterus by lifting up the cervix and womb by two fingers while pressing down on the woman’s lower abdomen with your outside hand. Try feeling uterus between two finger and your hand.

11.You will know you are pressing on the uterus when you feel the cervix move.

12.Feeling uterus takes practice. It is especially difficult to feel woman’s uterus with strong abdominal muscles or with a lot of abdominal fat.

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Calculating Gestational Age

Palpation of abdomen:

Gently palpate the fundus on the abdomen
Palpable just above symphysis pubis, (gestational age is probably 12 weeks)
Palpable halfway between symphysis pubis and umbilicus,
(gestational age is probably 16 weeks)
Palpable at the same height as the umbilicus, (gestational age is probably 22 weeks)
Palpable at 1 finger under the umbilicus
(20 weeks of gestation)
and 1 finger above (24 weeks of gestation)

(Bettercare, n.d.)

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Calculating Gestational Age

Determining gestational age after 18 weeks gestation:
Feel for the fundus of the uterus, and mark at the highest point of the fundus
Measure the symphysis-fundus (SF) height by measuring distance from the top of the symphysis pubis to the top of the uterus marked
Assess whether determined SF height corresponds to the patients date and size of fetus

(Bettercare, n.d.)

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Red Flags: Signs of Ectopic Pregnancy

Vaginal bleeding and pelvic pain
Shoulder pain, lightheadedness, fainting
Bimanual exam, if performed, should be done gently in suspected ectopic pregnancy due to chances of tube rupture
Unusually high levels of Hcg may indicate molar pregnancy

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Case study:

A 36-year-old gravida 4 para 3 patient presents at her first antenatal clinic visit. She does not know the date of her last menstrual period. The symphysis-fundus height measurement suggests a 32-week pregnancy.

Which would be the most accurate method for the nurse to use in determining gestational age in this case? Why?

Would an ultrasound examination be helpful in determining the gestational age? why?

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Which would be the most accurate method for the nurse to use in determining gestational age for this case? Why?

This is the most accurate clinical method to determine the size of the uterus from 18 weeks gestation. If the uterine growth, as determined by the symphysis fundus measurement, follows the curve on the antenatal card, the gestational age as determined at the first visit is confirmed.

Other methods of determining gestational age require accurate information on the first day of the last monthly period which the woman does not remember. So, they do not apply.

Ultrasound examination accurately determines the gestational age only up to 24 weeks gestation.

Would an ultrasound examination help determine the gestational age? Why?

No, the ultrasound examination accurately determines the gestational age only up to 24 weeks. So, it does not apply in this case.

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Reference:

ACOG (2018). Ectopic Pregnancy. Accessed from: https://www.acog.org/patient-resources/faqs/pregnancy/ectopic-pregnancy

Bettercare (n.d.). Primary maternal care: 1A Skill: General examination at the first antenatal visit. Accessed from: https://bettercare.co.za/learn/primary-maternal-care/text/01a.html#1a-skills-general-examination-at-the-first-antenatal-visit

Klein, S. Miller, S., & Thomson, F. (2020a). Questions in a pregnancy health history. A Book for Midwives; Care for pregnancy, birth, and women’s health. Berkeley, California: Hesperian Health Guides. Accessed from:

https://en.hesperian.org/hhg/A_Book_for_Midwives:Questions_in_a_pregnancy_health_history

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Reference:

Klein, S. Miller, S., & Thomson, F. (2020b). The bimanual exam (2-hand exam). A Book for Midwives; Care for pregnancy, birth, and women’s health. Berkeley, California: Hesperian Health Guides. Accessed from:

https://en.hesperian.org/hhg/A_Book_for_Midwives:The_bimanual_exam_(2-hand_exam)

Mayoclinic (n.d.). Ectopic Pregnancy. Accessed from : https://www.mayoclinic.org/diseases-conditions/ectopic-pregnancy/symptoms-causes/syc-20372088

Stanford Children’s Health (n.d.) Signs of Pregnancy/The Pregnancy Test. Accessed from- https://www.stanfordchildrens.org/en/topic/default?id=signs-of-pregnancythe-pregnancy-test-85-P01236

A Book for Midwives. Care for pregnancy, birth, and women's health. Authors: Susan Klein, Suellen Miller, and Fiona Thomson

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