📅 Prenatal Assessment, GTPAL & Dating
Counting pregnancies, dating the birth, and the three levels of certainty that decide whether a sign is presumptive, probable or positive.
⭐ GTPAL
- G — Gravida: total pregnancies, including the current one
- T — Term births, 37 weeks and beyond
- P — Preterm births, 20 to 36+6
- A — Abortions, losses before 20 weeks (spontaneous or induced)
- L — Living children right now
Twins count as ONE pregnancy and ONE birth, but TWO living children. That is the most commonly missed part.
🧠 Worked example
A woman is pregnant now. She has had: a term daughter, twin boys born at 34 weeks (both alive), and one miscarriage at 10 weeks.
| G | T | P | A | L |
|---|---|---|---|---|
| 4 | 1 | 1 | 1 | 3 |
G = 4 (current + daughter + twins + miscarriage). P = 1 because the twin pregnancy was one preterm birth. L = 3 because three children are alive.
👀 The three levels of certainty
| Level | Source | Examples |
|---|---|---|
| Presumptive | What she feels — subjective | Amenorrhoea, nausea, fatigue, breast tenderness, quickening |
| Probable | What the examiner finds | Positive pregnancy test, Goodell’s, Chadwick’s, Hegar’s signs, Braxton Hicks, ballottement |
| Positive | Comes from the fetus itself | Fetal heart tones, ultrasound visualization, examiner palpates fetal movement |
A positive pregnancy test is only PROBABLE, not positive.
hCG can be raised by a hydatidiform mole and some tumors. Only direct evidence of the fetus — heartbeat, ultrasound, palpated movement — is positive.
The named signs, quickly:
Goodell’s — softening of the cervix.
Chadwick’s — bluish-purple cervix and vagina.
Hegar’s — softening of the lower uterine segment.
All three are probable, because they are caused by increased blood flow rather than by a fetus.
📅 Dating and routine care
Nägele’s rule
LMP − 3 months + 7 days + 1 year
Example: LMP 10 May 2025 → minus 3 months = 10 February → plus 7 days = 17 February 2026.
It assumes a regular 28-day cycle, so it is an estimate. Ultrasound dating in the first trimester is more accurate.
📏 Fundal height
- 12 weeks — at the symphysis pubis
- 20 weeks — at the umbilicus
- 20–36 weeks — height in cm roughly equals weeks of gestation
More than 2 cm off suggests growth restriction, macrosomia, multiples, or a fluid problem.
📆 Visit schedule and what is checked
| Weeks | Frequency |
|---|---|
| Up to 28 | Every 4 weeks |
| 28–36 | Every 2 weeks |
| 36 to birth | Weekly |
Every visit: weight, blood pressure, urine for protein and glucose, fundal height, fetal heart rate, and from later pregnancy, fetal movement.
🚨 Danger signs to teach at every visit
- Vaginal bleeding; gush or leaking of fluid
- Severe headache, visual changes, epigastric pain — preeclampsia
- Swelling of the face and hands (ankle swelling alone is normal)
- Decreased or absent fetal movement
- Persistent vomiting; fever; burning on urination
- Regular contractions before 37 weeks
🎯 NCLEX traps
- Twins = one G, one birth, two L
- Positive pregnancy test is only probable
- Only fetal heart tones, ultrasound or palpated movement are positive
- Fundal height ≈ weeks between 20 and 36
- Face and hand edema is abnormal; ankle edema is not