• Presumptive Signs:[Pregnant woman notices] Maternal physiological changes that a woman may experience.
  • Abrupt cessation of menses
  • Nausea and vomiting
  • Tingling, tenseness, nodularity, and enlargement of breasts and nipples
  • Increased frequency of urination
  • Fatigue
  • Color changes of breast:  darkening of nipples; primary and secondary areolar changes
  • Appearance of Montgomery’s tubercles (glands, breast-around nipple)
  • Continued elevation of BBT in the absence of infection
  • Expression of colostrom from nipples (3rd trimester)
  • Excessive salivation
  • Quickening (first feel the baby move)
  • Skin pigmentation and conditions, e.g. chloasma, breast and abdominal striae, linea nigra, vascular spiders, palmar erythema
• Probable Signs: [RN Notices] Maternal physiological and anatomical changes detected upon examination (other than presumptive signs)
  • Chadwick’s sign
  • Enlargement of abdomen
  • Change in the shape of the uterus
  • Ballotment (pateller test)
  • Palpation of fetal outline
  • Fetal movement palpated (probable or positive)
  • Piskacek’s sign
  • Hegar’s sign
  • Goodell’s sign
  • Palpation of Braxton Hicks contractions
  • Positive pregnancy test
• Positive Signs: Directly attributed to the fetus as documented by the examiner
  • *ONLY* Fetal heart tones
  • Ultrasound confirmation

 **Objective 2: Differentiate between quantitative and qualitative pregnancy tests

• Ask ahead of time: “How would you feel about being pregnant right now?”
• Pregnancy Tests: 
• Detect HCG(corpus luteum) in blood or urine; Recognition of hCG (or a subunit) by an antibody to the hCG molecule usually the $-subunit of hCG 
  • Qualitative:  positive or negative
    • Urine: morning sample is the best; but any will do
  • Quantitative:  provides an amount for hCG
    • Blood test: will give an amount (hCG can be detected in the serum 8-9 days after fertilization; and somewhat later in the maternal urine) –3 days after pregnancy
  • Clinical tests: sensitive at the time of missed menses

**Objective 3: Describe how to determine last menstrual period and estimated date of delivery

• Dating: LMP – 3months + 7 days 
• Nagele’s Rule: first day of LMP, minus three months, plus one week and one year.  This equal 280 days from LMP.  No research supports 280 days as the length of pregnancy.
• Example: Dec.1st (so,) Dec.1st-3months=Sept.1st + 7days=Sept.8th
• Research has shown that the pregnancy mean is closer to 283-284 days from LMP or 269-270 days from ovulation
• Always determine if LMP was a normal period for the woman. Spotting at the time of implantation is not uncommon.  This scanty bleeding may be interpreted as a period unless a through menstrual history is obtained.  Remember, LMP refers to the first day of her last NORMAL period.  If a woman is a poor historian and has difficulty determining her LMP, it may be useful to use holidays or other events to help her focus her memory.
• Gestational Wheel: At the beginning of the wheel is the 1st day of menses; outside of wheel calendar year. middle wheel months; also, 280 marker (40weeks) ex. Sept.10-June 17
• 

DATING METHODS Level 1 – most reliable

• 1.  LMP which is normal, regular, & certain (1-2 wk range of accuracy)
• 2.  Basal body temperature with coital record, showing ovulation & sustained temperature elevation. (2-5 days range of accuracy)
• 3. Ultrasound between 7 & 10 weeks of menstrual age, using crown-rump length to calculate gestational age. (accurate to within  3-5 days)
• 4. Serum hCG levels <10,000 on two separate occasions one week apart, rising appropriately. . (accurate to within  3-5 days)
• 5. Urine pregnancy testing, which may initially be negative, but becomes positive as soon as detectable levels of hCG are present in maternal urine. This timing will vary according to the type of urine test used.
• 6. Two ultrasounds <26 weeks gestational age, which estimate dates of delivery within 2.6 weeks of each other.  Use the EDD based upon the earlier ultrasound, unless obtained between 10 & 13.