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Diagnosis of pregnancy and maternal assessment
1. DIAGNOSIS OF PREGNANCY
AND MATERNAL
ASSESSMENT
Deepthy P.Thomas
1st year MSc nursing
Govt college of nursing
Alappuzha.
2. PRESUMPTIVE SIGNS OF THE PREGNANCY
• Breast changes.
• Nausea and vomiting.
• Amenorrhoea.
• Frequent urination.
• Fatigue and uterine
enlargement.
• Quickening.
• Linea nigra.
• Melasma.
• Striae gravidarum
3. PROBABLE SIGNS OF PREGNANCY
Chadwick’s sign.
Goodell’s sign.
Hegar’s sign.
Evidence on ultrasound of gestational
sac.
Ballotment.
Braxton’s hick contraction.
Fetal outline felt by the examiner.
4. POSITIVE SIGNS OF PREGNANCY
Demonstration of a fetal heart
separate from the mother’s
heart.
Fetal movements felt by an examiner.
Visualization of fetus by ultrasound.
7. Cervical signs
Goodell’s sign
6th week
Uterine signs
Size shape and consisitency
piscacek’s sign
Hegar’s sign
between 6-10 weeks
Palmer’s sign
as early as 4-8 weeks
8. IMMUNOLOGICAL TESTS FOR THE
DIAGNOSIS OF PREGNANCY
Agglutination inhibition tests:
Direct agglutination test:
The sensitivity is 0.2 IU Hcg/ml.
Enzyme-linked immunosorbent assay:
It is based on one monoclonal antibody that binds
the hCG in urine and serum. ELISA can detect hCG
in serum upto 1-2 mIU/ml and as early as 5 days
before the first missed period.
Fluroimmuno assay:
the fluroscence emitted is proportional to the amount
of hCG. it can detect hCG as low as 1 Miu/ml. FIA
takes 2-3 hours.
9. Immune assays with radioisotopes:
Radioimmunoassay:
It is more sensitive and can detect β
subunit of hCG upto 0.002 IU/ml in the
serum. It can detect pregnancy as early as 8-
9 days after ovulation. It requires 3-4 hours to
perform.
Immune-radiometric assay:
Uses sandwich principle to detect whole
hCG and require only 30 mts.
SELECTION OF TIME:
by 8-11 days after conception. The test is not
reliable after 12 weeks
10. ULTRASONOGRAPHY
Intra decidual gestational sac -29
-35 days of gestation.
Fetal viability and gestational age is determined
by detecting the following structures by
transvaginal ultrasonography.
Gestational sac and yolk sac by 5 menustral
weeks.
Fetal pole and cardiac activity- 6 weeks.
Embryo movements by 7 weeks.
Fetal gestational age is measuring the CRL
the fetal heart reliably by 10 th week.
11. SECOND TRIMESTER
SYMPTOMS
Quickening at 16 to 18 weeks
It denotes the perception of active fetal
movements by the women
Progressive enlargement of the lower
abdomen
GENERAL EXAMINATION
Cloasma
Pigmentation over the forehead
and cheek may appear at about 24th week.
12. Breast changes:
Breasts are more enlarged with prominent
veins under the skin.
Secondary areola specially demarcated in
primigravidae, usually appears at about 20th
week.
Montgomery’s tubercles are prominent and
extent to the secondary areola.
Colustrum becomes thick and yellowish by 16th
week.
Variable degree of striae may be visible with
advancing weeks
13. ABDOMINAL EXAMINATION:
Inspection:
linea nigra as early as 20th
week and Striae
Palpation
Fundal height
the height of the uterus is midway between the
symphysis pubis and the umbilicus at 16th
week.
At the level of umbilicus at 24th week.
At the junction of the lower third and upper
two-third of the distance between the
umbilicus and ensiform cartilage at 28th week.
14. ABDOMINAL EXAMINATION
The uterus feels soft and elastic
Braxton’s-Hicks contraction
Palpation of fetal parts
Active fetal movements
External ballotment
Auscultation:
Fetal heart sound:
Uterine souffle:
Funic or fetal souffle:
15. VAGINAL EXAMINATION:
The bluish discolouration:
Internal ballotment
INVESTIGATIONS:
Sonography:
Routine sonography at 18-20 weeks permits a
dilated survey of fetal anatomy, placental
localization and the integrity of the cervical canal
Fetal organ anatomy
MRI
17. Fundal height
The fundal height corresponds
to the junction of the upper and middle
third at 32 weeks.
Upto the level of ensiform cartilage at
36th week.
It comes down to the level of 32
weeks at 40th week because of the
engagement of the fetal head.
To determine whether the uterus
height is correspond to 32 weeks or
40 weeks, engagement of the head
should be tested.
18. Braxton’s-Hick contraction
Fetal movements are easily felt
Palpation of fetal parts
FHS
Sonography
Amniotic fluid assessment is
done to detect
oligohydramnios[AFI<5] or
polyhydramnios[AFI>25].
20. MATERNAL ASSESSMENT
aims of maternal assessment are:
To identify the high risk cases.
To prevent and detect and treat at the earliest
any complications.
To ensure continued risk assessment and to
provide ongoing primary prevention health
care.
To educate the mother about the physiology of
pregnancy, labour, newborn care and
lactation.
To discuss with the couple about the place,
time, and the mode of delivery.
21. PROCEDURES AT THE FIRST VISIT
The initial interview
Demographic data
Chief concern
Family profile
Present history
Past history
Obstetric history
22. Menstrual history
Gynaecological history
Personal history
Family history
PHYSICAL EXAMINATION
Baseline height and weight
measurement
Vital signs
Head and scalp
Eyes
Nose
Ears
Mouth and oral cavity
23. Neck
Breasts
Thorax
Back
Rectum
Extremities and skin
ABDOMINAL EXAMINATION
Preliminaries
Inspection
Palpation
Height of the uterus
Obstetric grips
24. Auscultation
The relationship of the fetus to the
uterus and pelvis
Lie
Presentation
Attitude
Denominator
Position
Presenting part
26. LABORATORY METHODS:
BLOOD STUDIES:
A complete blood count:
Genetic screen
Serologic test for syphyllis
Blood typing
Maternal serum alfa feta protein
Indirect coomb’s test
Antibody titres for rubella and hepatitis B
HIV testing
Glucose tolerance test
URINALYSIS
27. ULTRASONOGRAPHY
1ST TRIMESTER 2ND 3RD TRIMESTER
Confirm pregnancy
Confirm viability
Determine gestational
age
Rule out ectopic
pregnancy
Detect multiple
gestation
Use for visualization
during chori- onic
villus sampling
Detect maternal
abnormalities
Establish or
confirm date
Confirm viability
Detect
polyhydramnios,
oligohy- dramnios
Detect congenital
anomalies
Detect IUGR
Confirm placenta
placement
visualization
during amnio-
centesis
Confirm gestational age
Confirm viability
Detect macrosomia
Detect congenital
anomalies
Detect IUGR
Determine fetal position
Detect placenta previa or
abruptio placentae
visualization during
amnio- centesis, external
version
Biophysical profile
Amniotic fluid volume
Detect placental maturity
28. First Trimester Second and Third Trimester
1. Gestational sac location
2. Embryo and/or yolk sac
identification 3. Crown-rump
length
4. Cardiac activity
5. Fetal number, including
amnionicity and chorionicity of
multiples when possible
6. Assessment of
embryonic/fetal anatomy
appropriate for the first
trimester 7. Evaluation of the
uterus, adnexa, and cul-de-sac
8. Assessment of the fetal
nuchal region if possible
1. Fetal number; multifetal
gestations: amnionicity, chorionicity,
fetal sizes, amnionic fluid volume,
and fetal genitalia, if visualized
2. Presentation
3. Fetal cardiac activity
4. Placental location and its
relationship to the internal cervical
os
5. Amnionic fluid volume
6. Gestational age
7. Fetal weight
8. Evaluation of the uterus, adnexa,
and cervix
9. Fetal anatomical survey,
including documentation of
technical limitations
Components of Ultrasound Examination by Trimester
30. SPECIAL INVESTIGATIONS IN HIGH RISK
PREGNANCY
Maternal serum alpha fetoprotein
Triple test
Acetyl choline esterase (AChE)
Amniocentesis
Chorionic villous sampling
Fetal movement count
Cordocentesis
Vibroacoustic stimulation (VAS)
Fetal biophysical profile (BPP)
Modified biophysical profile
31. Fetal cardiotocography (CTG)
Doppler ultrasound velocimetry
Placental grading
Contraction stress test ( CST)
Amniotic fluid volume assessment
(AFV)
Amniocentesis in late pregnancy:
Pulmonary maturity:
Assessment of severity of Rh-
isoimmunisation
Amnioscopy
32. SIGNS INDICATING COMPLICATIONS OF
PREGNANCY
Vaginal bleeding
Persistent vomiting
Chills and fever
Sudden escape of clear fluid from
vagina
Abdominal or chest pain
Increase or decrease in fetal
movement