‘Good God!’ says he, ‘how snug and compleat it lies – I defy all our painters in St Martins lane to put a Child into such a situation.’
William Hogarth, on seeing the dissection of a foetus in utero
ULTRASOUND SCANS were first developed in Glasgow, by a professor of midwifery called Ian Donald who had heard of metalworkers using them to detect flaws in steel. The metalworkers would calibrate the ultrasound machines against their thumbs, because bone and flesh reflect sound waves differently. In the summer of 1955, Donald drove from Glasgow down to a boiler manufacturers in Renfrew, his car boot full of buckets of ovarian cysts and uterine tumours. He compared ultrasound images of the body parts with those he obtained from a slab of steak. Impressed with the results, he moved the machine out of the metallurgists’ workshop and into the clinic.
In 1958 he wrote up his findings in a paper called ‘The Investigation of Abdominal Masses by Pulsed Ultrasound.’ The sound waves worked as well to outline the dimensions of a baby’s skull as they did a cyst or a tumour, and Donald began refining the technique to monitor the growth and development of babies in the womb. Within a couple of decades his scanners were ubiquitous: I’ve seen cheap and simple machines used upcountry in East and West Africa, and in rural clinics in India. They’re indispensable now for monitoring the growth and development of the baby, to identify the position of the placenta (if it is too near the cervix it risks rupture in labour). They’re even used in the frenzy of delivery itself for a quick check of the baby’s precise position.
The technology has moved on: it’s possible these days to watch babies on ultrasound in three dimensions. The internet is suffused with these images; often the sonogram image is shown side by side with a photograph of the same baby hours after birth. Mothers bring printouts to my clinic: asteroidal contours pixelate against a black, starless background, reminiscent of images beamed back from deep space. But a closer inspection reveals them to be the most human of forms, beamed not from the reaches of the solar system but from the future.
Perhaps it’s the glimpse of the future they grant that makes these images so enchanting, or perhaps it’s because through most of human history the transformations of pregnancy have been hidden. There’s something transgressive, even uncanny, about them. Though woven by sound, they offer silent promises of what is to come.
AS A JUNIOR DOCTOR working in obstetrics I’d be asked to help out in antenatal clinics: a dozen or so women, in various stages of pregnancy, seen across the span of a morning. There was an ultrasound scanner somewhere behind a curtain but it wasn’t for routine use – it was enough to use faster more traditional methods of determining whether a pregnancy was proceeding well. The checks I was to perform have been standardised across the world, and are so formulaic that each woman brought a list of them to each appointment on a grid. Date of clinic visit was written on the vertical axis, and each check was given a box to be ticked along a horizontal. To complete an antenatal check, it was enough to work your way across the grid.
Pregnant women have an increased blood volume, their hearts beating for two (or three, in the case of twins), which may drive blood pressure up. Their pulse rate too can accelerate to cope, and a particularly elevated pulse hints at a problem. Kidneys can be affected, and I’d dip-test a bottle of urine to make sure that there was no blood or protein leaking out. I’d draw a blood sample from each patient to see if the haemoglobin and platelets were keeping up with the extraordinary demands being made on them: the blood counts of most women drop during pregnancy, their blood diluted by the increased volume. And I’d ask them whether they were suffering from any of the customary complaints of pregnancy: nausea, backache, heartburn, or the bony pain of a stretching pelvis.
These checks were to gauge how much the effort of pregnancy was proving a strain on each woman’s body; when they were complete I’d move on to check how the baby, or babies, were growing and changing in the womb. That new life may take root and, like some kind of magical fruit, begin to swell, is the most quotidian of marvels. But it is marvellous. It felt like a great privilege to chart that burgeoning change.
First to be assessed was the baby’s ‘lie’ in the womb, trying to feel the weighty, solid roundness of a head, the curve of a spine, the smaller, softer and more mobile globe of a tiny rump. The further on the pregnancy the more significant the ‘lie’; if the head was up (‘breech’), a discussion would be opened with the midwives about whether to plan a caesarean or a vaginal delivery. Next I’d measure the ‘height’ of the womb itself, using nothing more advanced than a tape measure. Beyond the middle weeks of pregnancy, irrespective of size or ethnicity, the distance in centimetres, from the pubic bone to the uppermost extent of the womb correlates almost exactly to the number of weeks a woman has been pregnant. This correlation is so responsive that in the final weeks of pregnancy, when the baby’s head drops deeper into the pelvis in preparation for labour I’d see a corresponding drop in this ‘fundal height’.
In her elegant account of her own pregnancy, Expecting, Chitra Ramaswamy wrote of how comforting this element of the antenatal visit was for her:
How reassuring to feel the old-school pressure of its end against the top of my pubic bone, drawing me up as if I were a length of fabric. Pregnancy was meticulous work, as precise as a dress pattern, and my bump always measured within a centimetre or so of the number of weeks I was pregnant.
The unravelled tape measure would follow the linea nigra or ‘black line’ of pregnancy, in which the skin from pubis to umbilicus darkens with the hormones of pregnancy. ‘It bisected my stomach like a ring around a planet or a veined streak of quartz encircling a pebble,’ wrote Ramaswamy, ‘evidence of a disturbance within. Some mysterious ancient change.’
The final phase of the antenatal check, listening to the baby’s heartbeat, was to be signed off on the grid with a scribbled ‘FHH’ – ‘foetal heart heard’ – a peremptory way to document something so auspicious. If foetal ultrasound images seem beamed from the future, so did these peculiar, mesmerising sounds: rapid, pristine heartbeats clattering above the stately bass of the mother’s own pulse.
AFTER BILLIE BAXTER’S precocious puberty I didn’t see her again until she was thirteen – having finished developing at an age when some boys have barely started. Amy brought her in. ‘Billie’s pregnant,’ she said bluntly, as soon as they’d sat down, her face haloed in anger. ‘I don’t know how it happened, and she’s certainly not telling.’ Billie sat hunched in the chair by my desk, face hooded, arms folded, gaze fixed on the floor. She didn’t know it, but she was mirroring her mum’s posture. ‘It doesn’t matter who he is,’ Billie said. ‘I’m not seeing him any more. You can’t make me get rid of it.’
‘Who’s going to look after the baby?’ Amy said, her voice beseeching, then menacing. ‘You can’t drop out of school at fourteen. For God’s sake, Billie!’ She looked across at me, pleading now. ‘I can’t be a grandmother! Not yet!’ Billie just folded her arms all the tighter. Her ex-boyfriend was fourteen, she said. She’d wanted to have sex with him. And she was going to have the baby.
In my area there are counsellors trained to support young women who’ve become pregnant in their teens, or need confidential advice about contraception. I picked up the phone and spoke to one of them – she gave me a time for Billie to attend the following day. I wrote the time and place on a slip of paper and handed it over, along with a prescription for some folic acid supplements. ‘If you’re sure you want to go ahead with this pregnancy, take one of these each day,’ I said, ‘they’re good for the baby.’ She sighed, took the prescription and stuffed it into her pocket.
The following day, the counsellor contacted me to say that Billie hadn’t shown up. I left a message, and in case she preferred to see a female doctor, left a time to come in and see one of my colleagues. But again, Billie didn’t turn up.
I spoke with Simon and Amy: they were both furious with Billie, and thought her decision more about being wilful and obstinate than about expressing a genuine desire for motherhood. Otherwise, the pregnancy was going well: she had a touch of nausea, was sleeping more than usual, but was still making it in to school. Her parents thought that she was taking the folic acid I’d given. Billie was early in pregnancy for review by the midwives, but there was a new scheme – one-to-one support for teenage mums, throughout pregnancy and for the first couple of years. It was called the ‘Family Nurse Partnership’; an idea planted in the United States in the early 1980s, recently sown in Scotland. Extra funding meant there was more midwife and nurse time to spend with the young pregnant women, and to support them. It encouraged healthier pregnancies, better language development for babies, better school outcomes for their mums, fewer subsequent pregnancies, and a dramatic improvement in keeping fathers engaged. The nurses and midwives of the scheme would liaise with Billie’s teachers, and start preparing her for what it would be like to be heavily pregnant at thirteen, and care for a baby at fourteen.
The partnership arranged an ultrasound scan: the pregnancy was about twelve weeks on, and the baby a strong, healthy girl.
Billie was seen regularly by the nurses of the partnership, but eight weeks passed before I saw her back in clinic. Her lower back was beginning to hurt, she said, and she wanted a medical letter excusing her from gym class. ‘How is it all going?’ I asked.
‘Fine,’ she said, and for the first time in years looked directly at me.
‘Did you have your twenty-week scan yet?’
‘It was amazing,’ she said, her face brightening. ‘Sometimes I just can’t believe that there’s a new person inside, waiting to come out.’ She put both hands on her belly, regarding it with an expression of fear mingled with pride. ‘It’s incredible when I can feel her moving inside me.’
‘And your mum and dad? How are they getting used to the idea?’
Her face fell.
FOR MILLENNIA, knowledge about midwifery care must have been passed orally between women, but rarely written down. The few writings that have survived from the classical period, written by men, suggest they understood little about pregnancy. ‘If a woman is pregnant with twins and either breast loses its fullness she will miscarry one,’ says one of the Hippocratic treatises, ‘if the right breast it will be the male child, or if the left, the female.’ Some women are alerted they are going to miscarry by a sudden easing of breast tenderness, but in Hippocrates, that observation is conflated with senseless ideas about twins.
By the Middle Ages, manuals of midwifery began to show how babies might be positioned within the womb in late pregnancy, in order to give some guidance as to how they might be helped out. The images were schematic and poorly drawn, but they at least acknowledged that the growth of babies is not the stuff of miracles, but of material facts – a matter of anatomy and physiology. Men and women both were beginning to imagine what they might be feeling when they put their hands on a pregnant belly. One of the first to have useful images was an early sixteenth-century textbook called The Byrth of Mankynde, written by Eucharius Roesslin. It tabulated the different ‘lies’ of a baby in the womb, and offered advice about how best to deliver the baby in each case.
South of the Alps, Roesslin’s contemporary Leonardo da Vinci was working on a far more accurate vision. Earlier in his career, he’d sketched out the ways in which he wanted to approach the mystery of new life and its development:
… begin with the conception of man, and [then] describe the nature of the womb and how the foetus lives in it, up to what stage it resides there, and in what way it quickens into life and feeds. Also its growth and what interval there is between one stage of growth and another. What it is that forces it out from the body of the mother.
Leonardo thought that a baby did not receive its own soul until birth (‘the same soul governs the two bodies … the things desired by the mother are often found impressed on the members of the child’), but others of his contemporaries believed it was somehow funnelled in from God at the ‘quickening’, when a pregnant woman began feeling movements within the womb – usually around twenty weeks. His Study for the Foetus in the Womb was made from a dissection he made of a woman who’d died at around this stage of pregnancy. Just as his images of coitus and conception prefigured those now obtainable with MRI scans, his images of the foetus in the womb are a hint of the 3D technology to come.
THE TRANSFORMATIONS OF PREGNANCY are as much social as physical: the pregnant woman’s belly becomes a kind of unwilling public property, and her choices a matter of open debate. Strange hands assume licence to poke and prod; others may tut-tut disapprovingly if she dares drink coffee in public, never mind wine. Pregnancy illuminates with an unforgiving light how much society pries into women’s bodies with more intensity, and with harsher judgement, than it does men’s. Virginia Woolf skewered this disapproval in Orlando: ‘the better to conceal the fact; the great fact; the only fact; but, nevertheless, the deplorable fact; which every modest woman did her best to deny until denial was impossible; the fact that she was about to bear a child’. But there’s a flip side to the public scrutiny of pregnancy which shows itself in a kind of wonder – a spellbound reification of the pregnant woman. For all our scientific understanding, an enchantment persists about new life forming within the body of another. Those intrusive hands may be hoping for some magic to rub off on them.
Margaret Atwood’s The Handmaid’s Tale describes a dystopian society in which fertility has plummeted, and women are subjugated as reproductive slaves. Atwood conveys both the sense of wonder that pregnancy inspires as well as the opprobrium meted out to many pregnant women. One of the captive women, Ofwarren, walks triumphantly into a shop frequented by the other handmaidens, her belly swollen like a ‘huge fruit’. Ofwarren’s hands lie over the dome of her abdomen as if protecting it, but also as if she hopes to absorb something of its vigour. The other women murmur excitedly; they long to touch her even as she glances haughtily at their own flat bellies. The tension in the room builds until one of the women mutters ‘show-off’. Chitra Ramaswamy captures this strange mingling of admiration with resentment: ‘How people stared, particularly women, with a deep, almost male gaze that bore an unnerving resemblance to lust,’ she writes of the later stages of pregnancy. ‘I began to realise that they weren’t really looking at me at all. To be pregnant was to be a kind of mirror. Women, especially, wanted to see themselves in you.’
LEONARDO’S IMAGES of how the foetus lies in the womb weren’t surpassed until the 1750s. The Scottish anatomist William Hunter saw the original folios among the Royal Collection in Windsor, and conceived an ambition to better them. Hunter was Queen Charlotte’s personal physician, a celebrity doctor and a Fellow of the Royal Society. He recognised how much progress Leonardo had made towards comprehending the changes of pregnancy, but also how much more there still was to understand. With a Dutch illustrator called Jan van Rymsdyk, then famous in London circles for the grace and precision of his illustrations, he began work on his magnum opus, the anatomical work for which he’s still best remembered: The Anatomy of the Human Gravid Uterus. Hunter had many enemies, was by report an insufferable narcissist, and was often accused of taking credit for others’ work. Rymsdyk later said of him, ‘it is a dishonest mean cunning, in making one self a great Man with other People’s Merit’. But the work the two men created is one of clear-sighted vision, a fusion of Enlightenment science with an aesthetic sensibility reminiscent of the Dutch masters. It’s a lesson in how scientific discovery can be a close cousin of art, and how much beauty can be revealed through anatomy.
The original drawings that Hunter made with Rymsdyk are held at the library of the University of Glasgow. I phoned ahead for an appointment – they’re held in black, sepulchral boxes, and the staff need a few days’ notice to bring them up from the archives. Each of the boxes needs its own table, and when they came up I saw that each was marked ‘RESTRICTED’. Opening them, I found seventy-two drawings across thirty-four mounted plates. It was necessary to handle them with gloves, slowly lifting each image from the box as if unearthing them.
Hunter’s interest was in relieving obstructed labour, and so his emphasis was on the final months of pregnancy. ‘I was so fortunate as to meet with a Gravid Uterus,’ he wrote cynically to a correspondent in February 1751, ‘to which, from that time, all the hours have been dedicated.’ The drawings are composed from about a score of these ‘meetings’; they move backwards through a sequence of women prematurely dead, from full-term pregnancy to the days following conception. Rymsdyk’s illustrations are of William Hunter’s own dissections, as well as those of his brother John – the three men likely worked at times in the same space. Hunter’s attitude to the dissected women is betrayed by his correspondence, and sounds shocking to modern ears. But in eighteenth-century London around one in fifty pregnancies ended in the mother’s death. For Hunter, the death of a pregnant woman was routine; he was driven by scientific curiosity to understand pregnancy, but also by the imperative to reduce maternal deaths. Prints of engravings were produced for the education of clinicians all over the Anglophone world.
The Special Collections department of Glasgow University Library is on the twelfth floor; as I spread Rymsdyk’s drawings across four tables I looked out over the city, and realised that I was within a few hundred yards of the lab where Ian Donald developed ultrasound. The foetal images hadn’t faded; the babies were so lifelike it seemed scarcely possible they were drawn in death.
The printed edition of the engravings is dedicated to Hunter’s sovereign George III, and attempts to impress upon the king the significance of his highly unconventional work:
Sir, this work had no other claim to the honour with which it is distinguished by YOUR MAJESTY, than as it illustrates one part of science hitherto imperfectly understood, it contains the foundation of another part of science, on which the lives and happiness of millions must depend.
Consistent with his interest in reducing maternal death, rather than understanding foetal development, Hunter often dismisses the baby with statements such as: ‘The Foetus, with two turns of the navel-string round its neck, requires no explanation.’ But Rymsdyk devotes great attention to the foetuses. Plate I shows the skin of the abdomen folded back like a mantle, the bulge of the womb filling the centre ground. Plate VI shows the same womb opened: a term baby in position, left arm extended, fingers curled as if plucking at strings. Her hair is stuck down with amniotic fluid as if sweating at the exertion of being born, or of dying.
Plate XX shows a baby in breech position, fingertips touched lightly together. In one drawing made at around eighteen weeks of pregnancy, the detail is such that you can make out the window frame behind Rymsdyk, reflected on the shiny amniotic membrane. The membranes have been peeled back so carefully that the amniotic fluid is undisturbed; we look down with the artist on the baby floating in the liquid. Of this fluid, Hunter wrote: ‘To the taste it is always very sensibly saltish: and a considerable quantity of common salt may be obtained by evaporating a large quantity of liquor’ – like a fragment of the sea carried inside.
Some of the illustrations show the pelvis seen length-ways, like Leonardo’s couple in coitus. Others have been drawn looking up at the swollen dome of the womb from between the thighs, as a midwife or obstetrician would gauge the progress of labour.
The final plate of Rymsdyk and Hunter’s The Anatomy of the Gravid Uterus shows the sac of the embryo in reducing size – a shrinking crystal in a droplet of dew – retreating to its own conception.
SIMON AND AMY came around to the idea of being grandparents. Billie went into labour at forty-one weeks – only slightly overdue, but normal for a first pregnancy. She went through twenty-six hours of agony, a perineal tear, stitches, haemorrhage, transfusions, and delivery with the help of forceps. She might have appeared to have completed puberty, but her pelvis still had years to grow; if she’d lived a century earlier, she would almost certainly have died.
But she gave birth to a healthy baby girl, called the baby Danielle, and, as Amy had predicted, went back to school while Amy and Simon took on the job of being parents. I had déjà vu: Simon or Amy back regularly in clinic, a child bouncing on his or her knee, asking me about wheezes, fevers, rashes and feeding.
‘It suits us you know, being a family of four,’ Amy said to me one day, with Danielle in her arms. ‘I didn’t expect it to, but it does.’
‘And Billie? How is she getting on?’ I asked.
She shrugged. ‘She plays with her a little bit, will pass me a nappy if I’m in the middle of changing her, but she never speaks about the pregnancy. It’s like it never happened.’ She looked down at Danielle, smiled at her and tickled her toes. ‘I’m keeping a close eye on this one though,’ she said; ‘I don’t want to be back here in a few years with a great-grandchild.’