DOROTHY AWUAH-PEASAH

LECTURER
 SIGNS AND DIAGNOSIS OF
PREGNANCY
• There are many signs the woman may have
when she suspects that she is pregnant. Some
of these signs can only be caused by
pregnancy and are known as positive signs.
• Others may be caused by conditions other
than pregnancy and they are called
presumptive signs.
• Thirdly, the probable signs are elicited by
the doctor but none of them are positive as
mistakes are liable.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
Presumptive Signs (possible)
1) Amenorrhoea:
If a normal healthy woman who has a regular
period misses a period, then it is possible that
she is pregnant. Nevertheless, failure to
menstruate may also be due to such
conditions as active T.B, severe anaemia,
severe malnutrition, thyrotoxicosis, change of
environment, ovarian cysts and fibroids,
discontinuation of the oral contraceptives,
extreme worries or anxiety and menopause.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
2) Breast Changes
Only significant in the primigravid woman.
Slight tingling may also be experienced by
non-pregnant women before a period.
Pigmentation may persist after parturition
on the primary areola. There can be fluid in
the breasts of some non- pregnant women
before menstruation in cases of ovarian cyst
and fibroids.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
3) Morning Sickness
About 50% of women suffer from morning
sickness between 4th – 14th week of
pregnancy, but vomiting may be due to
gastric disturbances, appendicitis, pyelitis
and malaria
 SIGNS AND DIAGNOSIS OF
PREGNANCY

4) Bladder Irritation
Frequency of micturition is due to
the pressure of the growing
uterus on the bladder. But it may
also be due to nervousness,
diabetes, urinary tract infection
and increased fluid intake.
SIGNS AND DIAGNOSIS OF PREGNANCY

5) Skin Changes
These include pigmentation, manifested as
chloasma, linea nigra, darkening of the
primary areola, formation of the secondary
areola of the breasts and the formation of
striae.
Skin changes may however, be due to
diseases of the liver and adrenal glands
(Addison’s disease), exposure to sunlight,
obesity and ascites.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
6) Quickening (feeling life)
• Movement of the fetus in utero first recognized by
the mother, between 16-20 weeks.
• The uterus has to be in contact with the
abdominal wall before any feeling of movement
is felt. Multip 16-18wks, Primig. 18-20 wks.
• We cannot rely on these feelings as she may
mistake bowel movements for quickening and
others imagine that they have fetal movements.
 SIGNS AND DIAGNOSIS OF
PREGNANCY

Probable Signs
The majority of these signs are elicited by the
doctor mainly by VE.
1. Hegar’s Sign: (softening of the isthmus) 6th – 12th
week
• Seldom now employed unless other tests are not
available as it may induce abortion. Two (2) fingers
are inserted per vaginum into the anterior fornix
and the other hand is placed on the abdomen with
the fingers directed behind the uterus. The fingers
of both hands meet because of the softness of the
isthmus which is marked at this period of
 SIGNS AND DIAGNOSIS OF
PREGNANCY

2) Jacquemier’s or Chadwick’s sign (8th week)

blue discoloration.
• Violet or blue discolouration of the vaginal
mucosa due to increased blood supply to
the pelvis. It may also be present in pelvic
cellulitis, tumours and retroversion.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
3) Osianders Sign (8th week onwards) pulsation in
lateral fornices
• Increased pulsation felt in the lateral
fornices due to increased vascularity
(blood rushing through the uterine arteries).
It may also be due pathological conditions
that cause pelvic congestion eg tumours,
pelvic cellulitis
 SIGNS AND DIAGNOSIS OF
PREGNANCY
4) Changes in the Uterus (8th – 14th week)
• The uterus changes in shape, size and
consistency. It becomes globular than pear
shaped, feels enlarged and soft.

5) Goodell’s Sign (softening of the Cervix) 10th

week onwards
• The cervix feels as soft as the lips or earlobe
while the non-pregnant cervix feels as hard
as the tip of the nose.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
6) Uterine Souffle
• This is a soft blowing sound heard on auscultation
and it corresponds with the mother’s pulse.
• It is due to blood entering the uterine vessels.
• It is not a reliable sign as it can also be head in
patients with fibroids and in the puerperium

Funic Souffle
• This is a hissing sound which corresponds to the
fetal heart beat. It is believed to be caused by
interference (obstruction) with the circulation in
the umbilical cord.
• Although it is diagnostic, it is also pathological.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
7) Braxton Hick’s Contractions (16th week
onwards)
• Painless uterine contractions felt on
abdominal palpation, occurring about
every 15 minutes and increasing in
intensity after the 35th week. They facilitate
the circulation of blood to the placental site
and also play some part in the development
of the lower uterine segment. They start
from eight weeks but the woman feels them
from 16th week onwards
8) Abdominal enlargement (16th week
onwards)
• No other condition makes the uterus
enlarge so rapidly and so progressively. It
may however, be due to cysts, fibroids,
ascites, tumours, fat, gaseous distension of
the bowels, full bladder.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
9) Ballottement: Tossing and shaking of the
fetus in liquor (16th – 28th week)
Internal ballottement
During the 16th week, the fetus is
small in relation to the volume of
amniotic fluid. A sudden tap on the
uterus consequently causes the fetus
to rise in the liquor and recede on
the examiner’s fingers.
 SIGNS AND DIAGNOSIS OF
PREGNANCY

External ballottement
Done by palpation through the abdominal
and uterine walls. The fetus is tapped, on
one side of the abdomen while the other
hand is placed on the other side of the
abdomen. The fetus hits the other hand and
bounces back to hit the first hand of the
examiner. However, it can be produced by a
pedunculated abdominal tumour.
 SIGNS AND DIAGNOSIS OF
PREGNANCY

10) Pregnancy Tests

a. Biological tests – seldom used

b. Immunological tests
c. Hormonal tests
 SIGNS AND DIAGNOSIS OF
PREGNANCY
A. Biological Pregnancy Tests

• These tests are based on the detection of

chorionic gonado-trophic hormone in the urine.
• It is present as 14 days after fertilization and
persists throughout pregnancy but disappears
10 days after delivery, abortion or intrauterine
death.
• They are accurate in about 98% of cases but
are not considered positive signs of pregnancy,
since they can also give positive results for a
woman who has a hydatidiform mole or a
chorionic epithelioma.
 SIGNS AND DIAGNOSIS OF
PREGNANCY

Immunological Pregnancy Tests

• They are based on antigen antibody

reaction and make use of the detection of
human chorionic gonadotrophic hormone
in the urine.
• They have a greater degree of accuracy,
about 90% and may be used as early as
10-14 days after the first missed period.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
• The patient may obtain the results
within 2 mins to 2 hours depending on
the type of test used.
• The commonest used these days is the
Pregnosticon test.
• These tests are available as kits,
containing all the reagents needed to do
a test.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
• In immunological tests, HCG
antiserum is added to the specimen of
urine. If the woman is pregnant, the
HCG antiserum will neutralize the urine
and there will be no reaction. If on the
other hand the woman is not pregnant,
the HCG antiserum will react with the
urine and there will be agglutination.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
• Hormonal Tests
• Progesterone and Oestrogen or combined
may be given by injection or orally. The
common one in use is menstrogen.
• If menstrual flow does not follow within a
certain length of time e.g. 7 days after the
last injection depending on the hormone
used, then pregnancy is about 95%.
• Unfortunately, these may act as abortificient
and therefore it is not recommended of late.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
• Pregnanediol excretion test
• Progesterone in the urine is called
pregnanediol. As pregnancy advances
it increases from 4ml-10mls daily.
• However, it is a strong presumptive
sign of pregnancy because in ovarian
tumours this is evident.
 SIGNS AND DIAGNOSIS PREGNANCY

Positive signs
1. Fetal parts felt on palpation
• These can be felt through the abdominal wall
about 22-26th week of pregnancy. They are
the head, body and limbs of the fetus. It
would not be confused with eg fibroids.
2. Fetal movements felt or seen
• These can be felt by the midwife by the 22nd
week on palpation. It should not be confused
with movements felt by the mother
(quickening).
 SIGNS AND DIAGNOSIS OF
PREGNANCY
3. Fetal heart sounds heard on
auscultation
• These sounds are heard as early as 20th –
26th week.
• The rate is approximately 120-160 b.p.m.
i.e about twice the mother’s pulse.
• When the abdominal wall is thick,
amniotic fluid excessive or examination
room is noisy the heart sounds may be
inaudible.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
4. Xray (radiology)
• This will show the fetal bones from
16th week onwards but as x’ray would
damage the growing fetus especially
during the early months, it is not used
until the latter part of pregnancy.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
5. Ultrasonic detection (Ultrasonography)
a. Ultrasonic echo sounding can be used to
detect pregnancy as early as 3 days after
missing a period. It can also detected the
existence of twin pregnancy as early as 3
weeks. The apparatus used is the B-Scan.
b. The fetal sac can be seen on oscilloscope
screen or recorded by a Polaroid camera
as an ultrasonogram as early as 6 weeks
of gestation.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
c. Electronic detection of the fetal heard sound
• The Doptone, Sonicaid and Smith Kline
instruments can be used to detect fetal
heart sounds as early as 8 weeks after the
last menstrual period.
• It can determine the placental site before
amniocentesis or intrauterine transfusion.
• It can also differentiate a normal
pregnancy from a missed abortion.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
Signs of a Previous Pregnancy
• Occasionally it is of practical
importance for a midwife to decide
whether the patient has previously
given birth to a child.
• The second stage of labour may be
very rapid in a multiparous woman
and if the midwife is of the opinion
that the woman is a primigravida, she
may not be “scrubbed up” for delivery
in time.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
• The breasts
• These are flabby and the nipples are
prominent in women who breastfed their
infants. Striae similar to those on the
abdomen are present. Pigmentation of the
areola may still persist in brunettes.
• The abdomen
• The abdominal muscles are more lax and the
skin loose, so that there may be anterior
obliquity of the uterus and bulging of the
colon at the sides of the abdomen.
• The uterus is readily palpated in them and
the contours of the uterus is round and broad
instead of ovoid. Striae gravidarum are
silvery-white.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
• The genital tract
a. The vulva gapes and is more patulous.
b. The labia minora tend to project below
the majora and are darker in colour.
c. The vaginal walls are relaxed, the
vaginal orifice is larger and a cystocele
may be evident. The hymen is
transformed into carunculae
myrtiformes.
 SIGNS AND DIAGNOSIS OF
PREGNANCY
Pseudocyesis (Phantom or false
pregnancy)
• Applies to the condition in which a woman
shows several of the signs and symptoms of
pregnancy, such as breast changes, enlarged
abdomen and firmly believes she is pregnant
and yet no pregnancy exists.
• Usually observed in patients nearing their
menopause and infertile married women
who are intensely desired to be pregnant.
When it occurs in younger people there may
be irregularities of the menses but careful
examination reveals the diagnosis.
• If still in doubt, patient is examined under
 SIGNS AND DIAGNOSIS OF
PREGNANCY
d.The fourchette is absent.
e. The perineum is lax and scars from
previous lacerations or episiotomy are
seen.
f. The Os uteri is nearly always a
transverse slit instead of a round
opening
 SIGNS AND DIAGNOSIS OF
PREGNANCY
The Duration of Pregnancy
• The actual duration of pregnancy is
believed to be about 266 days from the
date of conception but there is no
accurate method of calculating this.
• Ovulation usually occurs 14 days to the
onset of the next period but it may be
delayed.
• As the exact date of fertilization is not
known an allowance of 2 weeks is given
280 days.
• The ovum is only capable of fertilization
for 36 – 48 hours but conception has been
 SIGNS AND DIAGNOSIS OF
PREGNANCY
Calculation of the Date of Confinement or
Delivery
• For practical purposes, the date of the last
menstrual period has proved to be a reliable
guide.
• By adding 7 days to the 1st day of the last
menstrual period and counting back 3
months or forwards 9 months and adjusting
the year when necessary a total of 280 days,
the expected date of delivery is arrived at.
• But the baby may be born one week or two
before or after that date and yet be at term. It
has been estimated that only 5% of women go
 SIGNS AND DIAGNOSIS OF
PREGNANCY
• The above is based on a 28-day menstrual
cycle. If she has a shorter cycle, deduct the
number of days from the EDD after
calculating it and getting the answer, if it is a
longer cycle, add the number of days in
difference, also after calculating it.
• When the periods are irregular or she
forgets her LMP add 22 or 24 weeks to the
date of quickening. The fundal height is also
used as a means of assessing the period of
gestation but it is fallacious.
SIGNS AND DIAGNOSIS OF
PREGNANCY

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