Normal Pregnancy

Conditions for a Normal Pregnancy

A pregnancy is clinically considered to be normal only when the following simple conditions are met:

• The fertilized ovum is growing safely inside the cavity of the uterus (not in the tubes).
• One fetus is forming, along with exactly one placenta and two membranes.
• There is a normal amount of amniotic fluid, which is about 1000 to 1500ml of liquor amnii.
• The baby is in a vertex presentation (meaning the head is pointing downwards, ready for birth).
• There is absolutely no bleeding from the vagina until the "show" appears during the very first stage of labour.
• The mother must remain healthy and strong, with no serious diseases or disorders related to the pregnancy.

Signs and Symptoms of Pregnancy

When a woman misses one or two of her regular menstrual periods, she may start to suspect that she is pregnant. In most cases, her guess is correct with a very high accuracy of about 98%, especially if she has always had a regular menstrual cycle.

To make it easy to understand, midwives classify the signs of pregnancy into three main groups:

1. Presumptive signs (Things the mother feels)
2. Probable signs (Things the health worker can see or feel)
3. Positive signs (100% proof that there is a baby)

1. Presumptive Signs

These are the very first signs a woman will notice. They make us "presume" or guess she might be pregnant, but they are not 100% sure because other sicknesses can cause them.

• Amenorrhea: This simple word refers to the absence of menstruation (missing a period). A woman may report missing one or two periods, which is a very strong indicator of pregnancy. However, we must be careful because amenorrhea can also be caused by using family planning methods, changing environments, long illnesses, or even high emotional stress.
• Breast changes: Many women feel a tingling and prickling sensation in their breasts. The breasts will also start to enlarge and feel very tender or painful to touch. These changes are very common early signs of pregnancy as the body prepares for breastfeeding.
• Morning sickness (nausea and vomiting): About 30% to 50% of pregnant women will feel sick to their stomachs and vomit. This usually happens between the 4th and 14th weeks of pregnancy. While bad food or other sicknesses can cause vomiting, if a woman has both nausea and a missed period, it strongly suggests she is pregnant. This sickness usually stops completely by the end of the first three months (first trimester).
• Increased frequency of urination: Because the uterus is growing, it sits directly on top of the bladder and presses down on it. This pressure causes the mother to make many trips to the bathroom to pass small amounts of urine. This is usually felt before 12 weeks of pregnancy. It gets better and decreases once the uterus grows big enough to rise out of the pelvic bone area at around 12 weeks.
• Skin changes: As the pregnancy grows, the mother's skin goes through many visible changes. The hormone responsible for all these dark skin changes is called the melanin hormone, and it is produced by the anterior pituitary gland in the brain.
  • Striae gravidarum: These are the common stretch marks. They begin to appear around the 16th week of pregnancy and are mostly found on the mother's abdomen, thighs, and breasts.
  • Chloasma (mask of pregnancy): Some women will develop dark, brownish patches of skin directly on their face. This looks like a mask.
  • Linea nigra: A very dark line will appear running straight down the middle of the mother's stomach, passing both above and below the umbilicus (belly button).
  • Darkening of areolas: The primary areolas (the dark circle around the nipple) will become even darker, and a second, lighter ring called the secondary areola may form around it.

• Quickening: This refers to the very first time the mother feels the baby moving or kicking inside her womb. This usually happens around 18 to 20 weeks of pregnancy for a "primigravida" (a woman who is pregnant for the very first time). For a "multigravida" (a woman who has been pregnant before), she might feel it earlier, around 16 to 18 weeks. Quickening is very helpful for a midwife to estimate the age of the pregnancy if the mother does not remember the dates of her last period.
• Fatigue: Pregnant women often feel extremely tired and sleepy. This is caused by the body working hard to produce extra blood, having lower blood sugar levels, and experiencing a drop in blood pressure caused by the hormone progesterone. Not sleeping well and morning sickness can also add to this feeling of severe tiredness.
• Mood changes: Because of the physical stress, changes in the body's metabolism, tiredness, and big changes in hormones (especially progesterone and estrogen), pregnant women will often experience mood swings, crying easily or feeling sudden anger or sadness.

2. Probable Signs

Probable signs are strong physical signs that the midwife or doctor can feel or see during a medical examination. They make it highly likely that the woman is pregnant.

• Hagar’s sign: This sign can be found between the 6th and 12th week of pregnancy. To detect it, the midwife performs a vaginal examination by inserting two fingers into the anterior fornix of the vagina, while her other hand gently presses the uterus from the outside of the abdomen. When the fingers from both hands meet, the midwife can feel a very distinct softening of the lower part of the uterus (the isthmus). This strongly indicates pregnancy.
• Jacquemier’s sign: This refers to the bluish or purple discoloration of the walls of the vagina. It becomes easy to see from the 8th week onwards. This color change happens because there is a lot of extra blood flowing to the pelvic area (pelvic congestion).
• Osiander’s sign: This is an increased, heavy heartbeat or pulsation that the midwife can feel on the side walls (lateral fornices) of the vagina. This sign can be felt from the 8th week onwards and happens because there are many more blood vessels bringing blood to the area to support the pregnancy.
• Softening of the cervix (Goodell’s sign): Starting from the 8th week of pregnancy, the hard cervix becomes very soft. To understand this easily: a non-pregnant cervix feels firm and hard, exactly like the tip of your nose. But the cervix of a pregnant woman feels very soft, just like your lower lip.
• Uterine soufflé: When a midwife uses a stethoscope to listen to the mother's abdomen, she might hear a soft, blowing sound. This sound starts around the 16th week of pregnancy and is simply the sound of extra blood rushing through the large blood vessels supplying the uterus.
• Abdominal enlargement: The uterus grows quickly and steadily from the 16th week onwards. This growth can be clearly seen with the eyes and felt with the hands when examining the stomach. This helps prove it is a pregnancy and not just a stomach full of gas, a full bladder, or fibroids.
• Braxton Hicks contractions: These are very mild, painless tightenings of the uterus that begin from the 16th week of pregnancy. They are perfectly normal practice contractions. The midwife can feel the stomach get hard approximately every 15 minutes during an examination.
• Internal ballottement: This is a technique where the midwife places fingers inside the vagina and gives the cervix a sharp, gentle upward tap. This causes the fetus inside to float high up into the amniotic fluid. When the fetus slowly sinks back down, it bumps against the midwife's waiting fingers. This bouncing movement can be felt between the 16th and 28th weeks.
• Presence of hCG (Human chorionic gonadotropin): This is the pregnancy hormone. It can be found in a woman's blood as early as 9 days after she gets pregnant, and it shows up in her urine about 14 days after conception. A positive test is a very reliable sign of pregnancy, though sometimes it can also be positive if a woman has a disease called a hydatidiform mole.

3. Positive Signs

Positive signs give us 100% undeniable proof that the woman is pregnant. These signs come directly from the baby itself.

• Fetal heart sounds: The baby's heart actually starts beating around the 4th week, but we can hear it clearly by the 24th week using a fetoscope (Pinard horn). If we use a modern Doppler machine, we can hear it very early, at just 10 weeks. A normal baby’s heart beats very fast, ranging between 120 and 160 beats per minute. The midwife must carefully listen to make sure she is hearing the fast baby's heart, and not the slower whooshing sound of the mother's own blood (uterine soufflé).
• Ultrasound scanning of the fetus: Using a scan machine, we can take real pictures of the baby. As early as the 4th week, the tiny embryo can be seen. By the 10th week, the baby’s head, arms, and legs begin to show clearly on the screen.
• Palpation of the entire fetus: A trained midwife can use her hands to feel the mother's stomach and clearly identify the baby's actual body parts. She will be able to feel the hard, round head, the long smooth back, and the small kicking arms and legs. This confirms the baby’s position and size.
• Palpation of fetal movement: After the 24th week of pregnancy, a skilled health worker can place their hands on the mother's stomach and clearly feel the baby kicking, rolling, and moving around.
• X-ray: An X-ray machine can show the baby's full bone skeleton as early as the 12th week. However, this is not a recommended method. We never use X-rays just to confirm pregnancy because the dangerous radiation can pass into the womb and harm the growing baby, causing birth defects (genetic alterations) or damaging the baby's reproductive organs. Ultrasound is much safer.
• Actual delivery of the baby: The final and most absolute confirmation of pregnancy is when the mother goes into labour and actually delivers a live newborn baby into the hands of the midwife!

Differential Diagnosis (Things That Look Like Pregnancy)

Sometimes, a woman's stomach gets big and her periods stop, but there is no baby inside. The midwife must think about other sicknesses that can mimic pregnancy. Some of these false alarms include:

• Ovarian cysts: A woman can have large bags of fluid (cysts) growing on her ovaries, causing her stomach to swell. When the midwife feels the stomach, this swelling feels different from a pregnant uterus. Most importantly, if we test her urine, the pregnancy test will be negative.
• Fibroids: These are hard, non-cancerous lumps of muscle that grow inside the walls of the uterus. They can make the stomach look very large, just like a pregnant mother. However, fibroids feel like hard, bumpy masses, and the pregnancy test will always remain negative.
• Distended urinary bladder: Sometimes a person fails to pass urine, and the bladder fills up with so much fluid that the stomach swells out like a pregnancy. The solution is simple: the health worker inserts a catheter tube to drain the trapped urine, and the stomach immediately goes back to being flat. There will be no other signs of pregnancy.
• Pseudocyesis (False or Phantom Pregnancy): This is a psychological condition. It happens when a woman wants a baby so badly, or is so stressed and afraid of being pregnant, that her mind tricks her body. She will stop seeing her periods, her stomach might swell, and she will feel like she has morning sickness. However, when the doctor does a scan or checks for the baby's heartbeat, nothing is there, and the urine pregnancy test is completely negative.