28 – SIGNS AND SYMPTOMS OF PREGNANCY
THE signs of pregnancy very considerably in different women, both as to their nature and the periods of their occurrence. The inquiry as to the existence of pregnancy is often one of great importance and anxiety, and we therefore place before the reader the most characteristic signs and symptoms to which this condition gives rise. In estimating the conclusiveness of these signs, reference must be had to their number and importance, the previous condition of the patient any accidental causes which may have been in operation of produce abnormal changes. Only four of the following signs can be considered as certain, and these only when clearly made out; they are-the sounds of the foetal heart, the movements of the child felt by another, fluctuation, and ballottement. The other signs are probable ones; probability, however, almost rising into certainty in some cases and at certain periods of gestation.
1. ABSENCE OF MENSTRUATION – One of the first circumstances which leads a lady to think herself pregnant is the arrest of the usual monthly discharge. If the suppression of the menses occur in a healthy woman, who had before been regular, and who has not been exposed to cold or wet, or any other accidental cause likely to influence the menses, and especially if at the second or third period the menses are still absent, pregnancy may be suspected. This sign will be much more conclusive if there are superadded to it other symptoms indicative of pregnancy, such as those described further on.
But although this is one of the earliest signs of pregnancy, still no certain conclusion can be arrived at from it, in as much as the menstrual function may be suppressed from causes altogether distinct from pregnancy – mountain air, an entire change of habits, a sea voyage, etc.; or conception may occur prior to the establishment of menstruation or immediately after ceasing to nurse, and before the function has had time to recur. Again, the menstrual discharge may be suspended as the result of disease, and conception may take place before the function is re- established.
It therefore follows that, though the absence of menstruation is of considerable value as evidence of pregnancy, it cannot, per se, be regarded as an absolute sign.
2. MORNING SICKNESS – Generally, in from two to six weeks, sometimes immediately after conception, ladies suffer more or less from nausea, and sometimes vomiting, on first taking the erect posture, probably from the uterine vessels being then more congested, and hence termed Morning sickness. Occasionally, these symptoms are so severe and persistent as very seriously to impair the health of the patient; on the other hand, some patients do not experience sickness at all.
In consequence of its intimate nervous connections with all parts of the body, the stomach often acts sympathetically in comparatively trifling derangements. Cerebral excitement, nervous irritation, affections of the bowels, kidneys, liver, etc., are all capable of exciting abnormal action in the stomach resembling that which attends pregnancy. As an isolated sign of pregnancy, therefore, this is one of but limited importance; it may be absent altogether, occur at unusual times, or take unusual forms; but when it is combined with other symptoms described in this chapter, occurs in the usual order of time, and there is no apparent cause for it, such an indigestion, and the tongue is clean, and the appetite and general health continue good in spite of nausea, it furnishes an important link in that chain of evidence which indicates the pregnant condition.
The treatment of this condition is described further on.
3. ENLARGEMENT OF THE BREASTS. – The examination of the breasts furnishes an experienced observer, acquainted with the general anatomy of the glands, with valuable data on which to found an opinion touching the existence of pregnancy. Generally, to about six or eight weeks after conception, often earlier, there occurs a sensation of fulness, with throbbing and tingling pain in the breasts, accompanied by their enlargement. They become larger, firmer, and feel knotty, and after a time a milky fluid may be secreted. But these symptoms cannot alone be relied upon as evidence of pregnancy, since irritation of utero-genital apparatus, suppressed menstruation, uterine tumors, or even, in some females, the appearance of the monthly discharge, may give rise to them. A temporary enlargement, simply consequent on marriage, is sometimes observable, without the occurrence of conception. Enlargement of the breasts may also be due to fatty deposit; but in this case other parts of the body will present evidence of a proportional increase of the fatty material. The true character of the enlargement is easily recognisable by the touch of the experienced finger; that from fatty enlargement is soft and uniform, but that from pregnancy is hard and knotty, and the lobules of the gland may be felt beneath the skin, arranged in a regular manner around the nipple. Enlargement from chronic disease is perhaps less likely to lead to an erroneous conclusion, as one breast only is involved, and that partially
4. DARKENING OF THE AREOLA AROUND THE NIPPLE – In the virgin state the colour of the nipple and areola is usually but a shade deeper than that of the skin generally; but in about six or eight weeks after conception, the delicate pink-coloured circle around the nipples becomes several shades darker, the circle increasing in extent, and in depth of colour, as pregnancy progress. This change is so strongly marked in primiparae, as to afford a good sign of gestation. It is, however, rendered of less general value from the fact that after the first pregnancy the dark colour becomes permanent, and is but little modified by subsequent ones. Concurrently with the altered colour of the areola, the nipples and surrounding integuments become swollen, puffy, and more moist, secreting a fluid which stains the linen; and the veins beneath the skin become more visible. Prominent points or glandular follicles, varying in the number from twelve to twenty, project from the sixteenth to the eighth part of an inch, immediately around the base of the nipple. These changes, which are often well marked, are not, however, always so. The darkening of the areola is less marked in women of light complexion; and something resembling it, as also enlargement of the mammary gland, is said to be present when the uterus is distended from other causes than pregnancy.
Alternations in the size and appearance of the breasts, the two signs just referred to afford to the educated hand and eye of the practitioner valuable evidence; they have also this additional importance, that an examination of them is easily obtainable, and, for various reasons, more readily conceded than one involving the vagina and abdomen.
5 MILK IN THE BREAST – This sign, considered very conclusive of pregnancy, is often unreliable. Women who have borne children sometimes continue to secrete milk for a long time – even for years; in such cases, therefore, this sign is of little value. Milk in the breasts also occurs in other conditions of the system besides pregnancy, and even in females who have never borne children.
6. ENLARGEMENT OF THE ABDOMEN – After impregnation, an increased efflux of blood occurs towards the womb, the tissues of which gradually expand, imparting a feeling of weight, fulness, and sensitiveness in the utero-genital organs.
The gradual enlargement of the uterus furnishes a tolerable accurate guide to the period of pregnancy, by the height which it attains in the abdomen. In about two months, the intestines are somewhat elevated, and by the end of the third month, the enlargement may be perceived; at the fourth month, the womb rises out of the pelvis in the form of a hard round tumor, and then gradually rises, and enlarges the whole abdomen. It reaches the umbilicus (navel) at the sixth months, and is highest at the night, when it reaches the ensiform cartilage, and impedes the descent of the diaphragm; during the last month it sinks a little, probably from some diminution of liquor amnii.
The sensation conveyed to the hand by the pregnant uterus is very different from that of the abdomen distended by fluid, flatus, etc.; the former being firm, elastic, defined; the movements of the foetus may be felt by the practised hand; but in the latter there is an absence of firmness and elasticity, and the tumor is not defined. On reaching the umbilicus, the uterus pushes it forward, so that in about the sixth month it is more prominent than natural, and afterwards it protrudes somewhat from the surrounding skin.
Enlargement of the abdomen, as a sign of pregnancy, is liable to variation; it may be distended by tympanitis 1 (1The Author was recently consulted by a married lady greatly desirous of offspring, in whom abdominal enlargement was so great that she was encouraged to make preparation for labour, the local medical attendant having sanctioned this view of her condition. We diagnosed the enlargement as a simple tympanitis of the abdomen, and prescribed Ignatia. In six days she presented herself with the enlargement wholly gone, and her health in other respects correspondingly improved.) or faecal accumulations in the intestines, or by ovarian dropsy; or the uterus may be enlarged by air, fluid, or hydatids. In many cases the abdomen even becomes flatter at first, from the sinking of the impregnated uterus in the pelvis, attended perhaps with a slight retraction of the navel.
7. QUICKENING – In popular language, this term is applied to the mother’s perception of the first movements of the foetus, on the incorrect assumption that it was not alive from very moment of conception. Quickening may be briefly explained thus:- As soon as the uterus has become too large to remain in the pelvis, it rises into the abdomen, sometimes suddenly, causing faintness and sickness; after this, the movements of the child, pressing directly upon the sensitive walls of the abdomen, are felt. If any doubt exists as to the date of conception, four months and a half from the date of quickening may be reckoned as a tolerably safe guide to the time of labour.
The sign of pregnancy is by no means a reliable one, unless the movements are certainly felt by another person, as the patient may be deceived by flatus in the intestines, or by the force of her own imagination; for women who think themselves pregnant often assert that they plainly feel the motions of the child, persisting in such statement until the lapse of time convinces them of their error. On the other hand, cases occasionally occur in which no sensation of the motion, of the child is perceived by the mother, from the beginning to the close of pregnancy.
8. FLUCTUATION – As early as the second or third month, pregnancy can often be diagnosed with certainty by this test. The tactus eruditus, possessed by the practised physician alone, is essential to make the test available. Holding the uterus steady with the left hand, an examination with two fingers of the right hand, an examination with two fingers of the right discovers the os uteri closed, the womb more or less enlarged, and by pressure or percussion a sense of fluctuation or perceptible movement of fluid is communicated. The fluctuation is a most importing sign, giving reliable evidence in a majority of cases. After the second month the fluctuation is more perceptible, but it may be recognised by the sixth or seventh week by a careful examination.
9. BALLOTTEMENT – At the expiration of a few weeks the uterus will be found lower than usual, heavier, and its os more circular, and closed; but afterwards it becomes higher, more difficult to be reached, and its neck shortened. If the woman be placed on her knees, and an impulse given to the finger, ballottement, or the floating of the child, may be felt, for it rises a moment in the liquor amnii, or fluid in which the foetus floats, and then, by its own gravity, sinks again on the finger. The most favourable period for this test is between the fifth and sixth months. Before the fifth month the foetus is too light and after the sixth month it is closely paced to admit of this feat. Ballottement is very conclusive of pregnancy and especially when corroborated by other signs, but determines nothing is to the life of the foetus.
10. KIESTEINE IN THE URINE – By keeping the urine of a pregnant woman a few days, a whitish scum, of a fatty or curdy appearance, forms on the surface, and then gradually breaks up again from decomposition, emitting a strong odour as of decaying cheese. Kiesteine is a mucilaginous principle, and probably exists in the urine from the first month of pregnancy until delivery, and arises from the excess of nutriment formed in the blood of the mother of the child.
11. SOUNDS OF THE FOETAL HEART. – By applying the stethoscope to the lower portion of the abdomen of either side, usually on the left, about midway between the umbilicus and the anterior superior spinous process of the ilium, the foetal heart may be heard at twice the rate of the mother’s. The sound has been compared to the muffled tickling of a watch, and the earliest time it can be heard is the beginning of the fifth month. When the pulsations of the foetal heart are heard, they are most positive of all the signs of pregnancy. At the same time, the pulsation may be inaudible, and yet the woman may be enceinte, as the foetus may have died, or the pulsations may be rendered inaudible only for a time.
It is by these pulsations that the SEX OF THE CHILD can in a large proportion of cases be ascertained during gestation. When the foetal pulsations reach 144 per minute, the child is probably female, but when they are 124 per minute probably a male. Any little variation from 124 upwards, and from 144 downwards, will not alter the diagnosis, provided auscultation be practised towards the end of pregnancy. Steinbach was correct in forty-five out of fifty-seven cases which he examined; while Frankenhauser was right in all the fifty cases which he examined with a view to determine the sex of the foetus in utero.
12. OTHER SIGNS OF PREGNANCY, which we can here only enumerate, are change of colour of the mucous membrane of the vagina to a dusky, livid hue, often well marked, and very characteristic; salivation; the uterine souffle, caused by the rush of blood through the tortuous arteries of the uterus over the placenta; sharpness of the features; irritability of temper; and, frequently, toothache, and other nervous complaints. Lastly, a frequent desire to pass water, especially in the night, is another early and valuable sign.
From the foregoing statements the reader will perceive that the diagnosis of pregnancy, especially in the early months, is far from being certain; the evidence is cumulative, no one sign being alone trustworthy, probability rising in proportion to the accumulation of the signs. Errors in the diagnosis of pregnancy usually arise from the attention of the observer being restricted to one or two signs only, and omitting to inquire for other corroborative ones.
29 – GENERAL HABITS DURING PREGNANCY
1. DIET – The diet should be simple, nutritious, and easy of digestion; it should be thoroughly masticated, and but little fluid drunk at meal-times, especially cold, since cold retards digestion. It is an error to suppose that women require more nourishment in pregnancy than at other times; and large quantities of rich food, taken in the belief that it will contribute to the sustenance of the child, cannot but be productive of baneful consequences. Spices, spiced meat, sausages, and all highly seasoned food, and late suppers, must be refrained from. Plainly cooked animal food (once a day), well- boiled vegetables, ripe fruits, and such articles as rice, tapioca, arrowroot, will, if taken in moderation, rarely disagree with the stomach. Pie-crusts, smoked hams, salted meats generally, rich sauces, and every article that has been known to occasion indigestion, must be eschewed. All substances that have a tendency to produce a costive state of the bowels should be especially avoided, and, unless some reason exists to the contrary brown bread should be eaten in preference to white,. Stimulating drinks – wines, ardent spirits, ale, porter, strong tea, and coffee – are, generally, hurtful both to the mother and the foetus.
2. DRESS – Under this head, the origin of the word enceinte, used to signify the pregnant condition, is highly suggestive. It was the custom of the Roman woman to wear a light girdle or cincture round their waists; but on the occurrence of pregnancy this restraint was removed. Hence a woman so circumstanced was said to be inciencta (onbound), and thus the term enceinte has been adopted to indicate pregnancy.
It would seem scarcely necessary to make any remarks upon the dress to be worn, were it not that some women, considerably advanced in pregnancy, often lace tightly for the sake of attending public entertainments, or of diverting notice from their condition. At no time should stays be worn, for the simple reason that they are never required. But they should especially be avoided during pregnancy, since a continual and forcible compression of the abdomen while nature is at work to secure its gradual enlargement in order to accommodate the growth of the foetus, must be attended with serious injury to the health of both mother and child. During gestation, the uterus increases on an average from two inches to fourteen in diameter. It will be obvious, therefore, how vain, as well as criminal, must be any effort to contract it, and thus to conceal its enlargement. Palpitation of the heart, indigestion, diseases of the liver, and costiveness; difficulty of breathing, spitting-of-blood, and persistent coughs; enlarged veins in the legs, swellings in the lower limbs, disorders of the womb, deformity of the offspring, and numerous other affections, have their origin in tight-lacing; and finally, if the child be born alive and moulded aright, and the mother escape her self-created perils, it may be questioned if compressed breasts and nipples can afford the requisite ailment.
The dress should be arranged both as to material and quantity, with the view of comfort and to the season. There must be no pressure on any part; even the garters should be loosely worn. The feet and abdomen should be kept warm, since habitual coldness of these parts predisposes to colic, headache, and Miscarriage.
3. EXERCISE – Exercise is a most important means of retaining good health during gestation, of securing a natural delivery, and of favouring the health of the infant. Walking in the open air is most useful kind; for this calls into action more of the muscles of the body than does any other exercise suited to this condition. Walking exercise is even more necessary in the winter than in the summer, and produces a much healthier and more lasting warmth than sitting before a fire. It should, if possible, be taken in the morning before dinner, and be of such a character as to interest the mind as well as to strengthen the body.
This will operate most favourably as a preventive host of the morbid conditions and feelings which are apt to attend this state. Care must, however, he taken to avoid such a degree of exercise as may induce positive fatigue; such as too long walks, going out in slippery weather, dancing, lifting heavy weights, and all kids of violent motion, which are liable to cause haemorrhage, Miscarriage, and bearing-down of the womb. The passive exercise of riding in a carriage falls short of the object in view; and, on the other hand, riding on horseback exceeds it, besides the danger of fright and accident, to which the incipient mother is then liable. In very wet or windy weather, or when it is impracticable to walk out, she should select a large and well-ventilated room, so that the air she breathes may be pure.
As an illustration of the advantage of taking exercise during pregnancy in out-of-door air, and in the broad light of day, we may mention the fact that the number of cretins in the Valais has considerably diminished since the women have adopted the practice of removing from the humid and sunless air of the valleys, and residing during pregnancy on the more exposed and cheerful heights.
It will be plain from the tenor of these general remarks, that lassitude and languor should be striven against and overcome. On this account the pernicious habit of sleeping after dinner should not be contracted. Too light sleep is perhaps even a less evil than too much. And hence ladies who pass the intervals, or a good part of it, between dinner and tea, on the couch or the bed, generally suffer from a debility which ends in proneness to disease.
4. ADDITIONAL HINTS – Theatres, balls, brilliantly lighted, or other exciting public meetings should not be attended; early habits should be formed; all excessive mental emotions, a grief, despondency, anger, and the like, are to be guarded; the cold or tepid bath should be used daily, following it with vigorous friction; the mind should be kept tranquil, remembering that parturition is not necessarily attended by great suffering, or imminent danger, these being, in most instances, the penalty inflicted on those who disregard the hints laid.