Читать книгу Obstetrics for Nurses - Charles B. Reed - Страница 11

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The presence of pregnancy is naturally determined by the recognition of those changes in the maternal system which the growing ovum produces.

During the second half of the period the fœtus can be made out distinctly by palpation, or by its movements, and the heart tones observed by auscultation.

During the first half this is impossible and the diagnosis must be made from subjective symptoms elicited from the patient and upon physical signs observed by the physician.

It is of extreme practical importance to be able to recognize a pregnancy at all periods. The subjective symptoms of the first half are—amenorrhœa, morning sickness, irritability of the bladder, discomfort and swelling of the breasts, enlargement of the abdomen and quickening; but the appearance of any or all of these phenomena is not to be regarded as conclusive, but merely as a presumption that pregnancy exists. Either through ignorance, intent to deceive, or from pathological conditions, any or all of these symptoms may be present, but not until the tenth week are the changes in the uterus sufficiently definite to confirm a diagnosis unless the circumstances are especially favorable.

Amenorrhœa.—Cessation of the menses is practically invariable in pregnancy. One or two periods may occur after conception, but care must be used to exclude other causes of hæmorrhage. Sudden cessation of the periods in a healthy woman of regular habits who is not near the menopause, is strongly suggestive of pregnancy. Why a developing ovum causes an immediate arrest of menstruation is not understood.

Amenorrhœa may occur in consequence of chlorosis, heart disease, hysteria, tuberculosis, fright, grief, and some forms of insanity; a change from a low to a high altitude, or an ocean voyage not infrequently causes the flow to remain absent for one or more months. In addition to its value as a presumptive symptom, the amenorrhœa affords a common and convenient method of estimating the date of confinement. The method is fallacious but practical, and will be discussed later.

Morning Sickness.—This symptom is not invariable. It is most frequent in primiparas, but not so likely to occur in subsequent pregnancies. It usually appears about the second month, shortly after the first period missed. It varies in intensity. Some women have a little nausea on arising and no further trouble during the day, others are nauseated and vomit either on rising or after the first meal, and yet others after each meal; but the general health is not ordinarily affected and the tongue remains clean. Some cases are of extreme severity (hyperemesis) and will be discussed elsewhere.

The morning sickness is probably toxic in origin. It must be remembered that chronic alcoholism is accompanied by morning sickness, but with it the tongue is furred.

Irritability of bladder is shown by a frequency of urination. It is caused by the congestion and stretching of the tissues that lie between the uterus and bladder and hold them in relation to one another. After the third month an accommodation is established and the symptom does not reappear until late in pregnancy, when the pressure of the heavy uterus tends to keep the bladder empty. If especially annoying, this irritability may be much relieved by putting the patient in the knee-chest position night and morning.

Enlargement of the breasts is common in primiparas, but this, with changes in the areola, may occur at menstrual periods in nervous women. Tingling, pricking and shooting sensations may also be noted.

Enlargement of the abdomen is only noticeable toward the latter part of the first half, when the uterus rises out of the abdomen.

Quickening means “coming to life,” and refers to the first movements of the fœtus that are felt by the mother. It is described as similar to the flutter of a bird in the closed hand. It is sometimes accompanied by nausea and faintness. Quickening usually occurs about the seventeenth week of pregnancy, and continues to the end. Gas in the intestines will sometimes simulate quickening.

The movements are important in the second half as indicating that the child is alive.

Physical Signs.—During the first weeks no conclusive changes occur that can be detected by examination, and unless conditions are especially favorable, the earliest time for the definite diagnosis of pregnancy is the eighth week. Previous to this it is presumptive only.

At the eighth week, the breasts may show enlargement and tenderness, with some secretion. In the multipara, this sign has no significance. Secretion is present sometimes in the breast of nonpregnant women with uterine disease (fibroids).

Examination of the abdomen at this time is of little value, but changes in the uterus can be detected by careful bimanual examination. It is needless to say that all internal examinations should be made with the utmost care and gentleness.

Softening of the lips of the os (Goodell’s sign) may be found, but it must not be confused with erosions of the os. The os of a nonpregnant woman feels like the tip of the nose, and that of the pregnant woman like the lips.

Fig. 26.—Bimanual examination. (Edgar.)

The increased size and globular shape must also be considered as confirmatory.

Hegar’s Sign.—The upper part of the uterus is soft and distended by the ovum, the lower part is soft and not filled out by the ovum. Between the two is an isthmus that is compressible between the fingers of one hand in the vagina, and of the other upon the abdomen. When found, this sign is of great value.

At the eighth week, pregnancy can be regarded as highly probable by the conjunction of the following symptoms and signs: Amenorrhœa, morning sickness, irritability of bladder, slight breast changes in primiparas, lips of os externum softened, uterine body enlarged, softened, and nearly globular in shape, and Hegar’s sign.

Abderhalden’s test is a serum reaction based on the well established principle that the introduction into the blood of an organic foreign substance leads to the formation of a ferment to destroy it. Abderhalden’s plan was to discover whether the blood of a pregnant woman contained a ferment capable of destroying placental protein. It is a very complicated test, and subject to many inaccuracies and numerous sources of error. At the same time, the main features of this reaction have been confirmed, and when it is worked out, it will be of immense value not alone in early uterine pregnancies, but in extrauterine pregnancy. This view very properly demands that pregnancy be regarded as a parasitic disease. It is practicable as early as the sixth week to make a diagnosis, and it only fails in possibly ten per cent of the cases. The negative test is equally definite as eliminating pregnancy.

Sixteenth Week.—Morning sickness and urinary symptoms have disappeared but amenorrhœa remains. Enlargement of the breasts is noticeable, as well as the increased pigmentation. The uterus begins to rise above the symphysis as an elastic, somewhat ill-defined, boggy mass. The cervix is softer. The characteristic dull lavender coloration of the vulvar mucous membrane is now evident. It is due to the congestion and is called Jacquemins’ sign.

Two New Signs.—Irregular, painless contractions of the uterus (Braxton Hicks’ sign), and ballottement.

The contractions of Braxton Hicks now become more easily palpable.

Ballottement consists in the detection in the uterus of a movable solid body surrounded by fluid. In a standing position, the fœtus rests in the lower part of the uterus, just above the cervix. The woman stands with one foot on a low stool, and two fingers of one hand are pushed into the vagina until they touch the cervix, the other hand is placed on the fundus. A smart upward blow by the internal hand is transmitted to the fœtus, and it can be felt to leave the cervix, strike lightly the tissues underneath the external hand, and return to the cervix. It is simulated by so few things, and so rarely, that in practice it must be regarded as a positive sign.

During the second half, the subjective symptoms are of minor importance since unmistakable evidence is furnished by the physical signs. The symptoms of this period are mostly discomforts. Increased intraabdominal pressure brings on edema of the feet, cramps in the legs, varicose veins of the legs and vulva, dyspnœa, and palpitations.

Twenty-sixth Week.—About the twenty-sixth week, or, at the end of the sixth calendar month, the hypertrophy of the breasts, the presence of secretion, and the marked pigmentation are unmistakable. The abdominal protrusion is now clearly visible, and the fundus will be found at the level of the upper border of the umbilicus.

Spontaneous fœtal movements appear and may be felt by the palpating hand.

Auscultation reveals the uterine souffle and the fœtal heart sounds. The heart sounds and the fœtal movements, when obtained by the observer, are positive signs.

Uterine souffle is a soft, blowing murmur, synchronous with the mother’s pulse. It is best heard at the lower parts of the lateral borders of the uterus. It is due to the passage of blood through the greatly dilated uterine arteries. It may be heard also in cases of fibroid tumors of the uterus.

Fig. 27.—Abdominal enlargement at third, sixth, ninth, and tenth months of pregnancy. (Williams.)

Fig. 28.—Height of the uterus at various months of pregnancy. (Bumm.)

The fœtal heart sounds are the most anxiously sought for of all the signs of pregnancy. They are conclusive. They not only determine the diagnosis, but afford valuable information during labor, and nurse and student should lose no opportunity of becoming familiar with them. The heart tones can be heard as early as the twenty-sixth week, but they become more and more distinct as pregnancy advances. They vary from 140 to 160 beats to the minute at the twenty-sixth week, and at term, from 120 to 140. When they rise above 160 or sink below 120, some danger threatens the child. The fœtal heart tones have no significance as an indication of sex.

Funic souffle is the sound made by the passage of blood through the umbilical cord when a loop accidentally lies under the tip of the stethoscope. It is synchronous with the fœtal heart tones, but of no great practical importance when the heart tones can be obtained.

Determination of the period to which pregnancy has advanced is sometimes important. This can be approximated by a calculation of the time that has elapsed since the last period, or from the date on which quickening has occurred. Measurement of the height of the fundus and comparison with such scales as Spiegelberg’s, may be carried out, but it is not often required.

A method of estimation in gross, that is approximately correct, in many cases depends on the observation of the steady growth of the womb.

Thus, the uterus rises out of the pelvis at the fourth month, and may be found well above the symphysis pubis. At the fifth month the fundus is midway between the symphysis and the umbilicus. At the sixth month it reaches the umbilical level. At the eighth month it is a little more than midway between the umbilicus and the ensiform cartilage, which it attains in another month, the ninth. Then it usually sinks a little, especially in primiparas during the last two or three weeks. This is called lightening.