Desperate Midwives

Before​ the invention of forceps in the early 18th century, a midwife presented with an irredeemably obstructed birth would insert a hook into the foetus’s skull to pull it out, or dismember it and remove its body in pieces. The foetus would – obviously – die, but the labouring woman might survive. The oaths women swore in labour were concerned with this problem of parting one body from another. They begged God to ‘make a way out’; ‘it seemeth that thou for my sins hast shut up the doors of my womb,’ one prayerbook reads, ‘and caused the babe to stand still like to be stifled.’ The terror was that ‘the child and I will never part.’ Only around 2 per cent of births in 17th-century England were stillborn as a result of obstruction. But it was the terror that counted, not the odds.

When my son had to be delivered by forceps, I saw the curved purple bruises on his cheeks as accusations. The parting hadn’t worked out and I was sure it was my fault. I tried to relieve my guilt by reminding myself to be grateful for modern medicine – at least he wasn’t removed with a crochet hook – but forceps aren’t modern. Nor do they feel modern. They feel like what they are: a product of 18th-century male practitioners’ devotion to metallic reason and elegance in all things. I had spent years in the archives trying to gain some intimacy with the past, and suddenly there I was, being penetrated by the Enlightenment.

The history of the body is a slippery subject. It encompasses the history of medicine, of gender and sexuality, of race, of science and theology and labour. It is a history of ideas (the four humours, say), a history of practices (bloodletting, footbinding, forceps delivery) and a history of materiality (corsets, tattoos). It can include birth and death, as well as everything before (conception), after (resurrection) and in between. It examines community (flagellants, holy anorexics) and singularity (Napoleon’s body, or Martin Luther’s). Its subject, most often, is language about the body; even when historians are talking about piss and shit and flesh they’re usually talking about words, which is understandable if frustrating.

One problem is that it’s so easy to forget that we ourselves are bodies in history. The history of the body always concerns someone who seems obviously both more embodied and more historical than you, like a medieval ascetic, or Emily Ratajkowski. But the fact that your own ordinary body is a product of history becomes unforgettable during birth. You are reminded that, were it not for modern medicine, you would be in extraordinary pain, or would have puerperal fever, or would be dead. In antenatal class, I was told that giving birth on your back is itself an artefact of history. Our teacher said that Louis XIV ordered his mistresses to give birth on their backs because he liked a clear view; Louis set a fashionable precedent that made labour longer and harder. Who better to blame for a protracted labour than a king with a kink? Of course, the anecdote is nonsense, but it is nonsense of an instructive kind. On the one hand, we are told that history is the enemy of pain and death, bringing the 19th-century invention of analgesics, survivable caesarean sections and infection control. On the other, history is the enemy of nature: its cultural interventions and fashions and fetishes undermine the unmediated, natural birthing body. Becoming a birthing person forces you to take a side and defend it against the overpowering force of maternal guilt.

Giving birth was the first time that I felt the body’s history in my own body, and it made me think differently about history. I once read about an oddball divinity student at Cambridge in the 1660s who was paid a guinea by the fellows of the Royal Society to have his body pumped with ten ounces of sheep’s blood (on condition that he would write up the experience, in Latin naturally). Early modern men and women electrified and modified their bodies, inhaled gases and transfused themselves, all in the pursuit of scientific knowledge. The body was experiment and evidence, truth and authority: the natural philosophers got there a few centuries before the feminists. An unfortunate thing about being a pregnant gender historian is that you shuffle leaking into the labour ward with your head full of facts, such as the existence of foetal craniotomy. But an ambivalent advantage is that your body itself can become an experiment in historical thinking. I doubt the experiment hurt less than electrocuting yourself would, but it was revealing.

‘What do you do?’ a midwife asked as she helped me to the bathroom. We were in the postnatal ward for people who have had a bad time of it. ‘I’m a historian of … all this,’ I answered, and gestured vaguely at the wreckage of the ward. Two and a half years on, I can say, expertly, continently: between the 16th and the 18th century, midwifery was transformed. At the beginning of the period, all midwives were women; by the end, male midwives were relatively common, especially in cities like Paris and London. Historians have seen this transformation in gendered practice as the crux of a set of related changes: the introduction of anatomical drawing into midwifery manuals; the increased acceptance and practice of intervention, both manual and instrumental; the professionalisation of midwifery from a relatively informal apprenticeship system to a discipline taught in medical schools, lecture tours, textbooks.

Rebecca Whiteley’s Birth Figures considers the images of foetal positioning that were included in printed midwifery manuals and helped midwives visualise the presentation of the foetus, whether it was cephalic (ideal) or breech (not good) or impacted (very bad), in order that they might better prepare for a complex birth.* These images become an occasion for an intricate meditation: on the nature of the womb, and the unseen; on the representation in static images of dynamic process and bodily transformation; on the contingent and shifting boundary between interior and exterior, nature and history.

The interpretation of developments in midwifery and its visual culture has been fiercely contested. The earliest (need it be said, male) historians of midwifery argued that this was a progressive story in which expertise and science and reason triumphed over the superstitions and backward practices of untrained female midwives. In the 1960s and 1970s, feminist historians described instead a loss of female authority at the hands of unsafe, overly interventionist male practitioners. (Female midwives were not permitted to use forceps.) More recently, historians have tried to chart a more moderate course. Monica Green has argued that men did encroach on midwifery practices, but much earlier than the early modern period; and that female midwives still undertook the vast majority of maternity care well into the Enlightenment.

Whiteley adopts this more moderate view. Male and female midwives fought viciously in pamphlet wars, but in practice, she argues, midwifery practice was not a gender war; a better way of viewing the history of midwifery is to ask who used the books. Whiteley traces the emergence of two spheres of midwifery practice across the late 17th and 18th centuries: regular and emergency midwifery. Regular midwives were primarily women, trained as apprentices but not institutionally educated. They attended normal labours, were embedded in their communities and provided both pre and postnatal care. Emergency midwives were normally men who had trained in medical schools, learned theoretical midwifery and anatomy from books, and were called in by regular midwives to attend complicated labours that required intervention.

This gendered division was not hard and fast – some men were regular midwives, some women attended emergency deliveries, and women wrote important midwifery manuals, too – but over the 18th century the gap between regular and emergency midwifery widened. This is a gap I know well, having traversed it on a hospital trolley. At Sheffield’s Jessop Wing, the distance between regular and emergency midwifery is as wide as a hallway: when things go wrong, they roll you across the hall from the electric-candle-lit midwifery suites into the bright whiteness of the obstetrician-led ward, where they keep the good drugs.

Changes in midwifery coalesced around the problem of whether it was possible to practise on the interior of the labouring body. By visualising that dark interior, birth figures assumed a critical place in these debates. Those made in the 16th century are odd, charming things. They show male, curly-haired toddler-foetuses doing joyful acrobatics in the womb: floating, leaping, flying around; smiling, fat two-year-olds who appear ready to dive effortlessly through the birth canal. These healthy putti were an argument for a midwife’s skills. They allayed the fear that the child might come out speared on a hook, or come out a girl.

In the 16th and early 17th centuries, literacy rates were high among midwives. They owned manuals that contained birth figures and formed part of their continuing professional education. Elizabeth Hunt inscribed her manual: ‘Elizabeth Hunt her Booke not his’. Another woman wrote in her copy of The English Midwife Enlarged: ‘Mary Hillyer her book/god give her grace ther/unto look not to look but/to understand larn [learning] is beter/then house or land.’ The woodcut birth figures in these books were not images drawn from observation – pregnant cadavers for anatomical drawing were hard to come by – but abstracted diagrams of the chaotic diversity of labouring bodies. They invited midwives to imagine the interior, and so to imagine practising on it.

Midwives were used to taking care of mothers, offering medicines, catching babies, cutting cords, washing and swaddling. Now, armed with images of what was happening inside, they could attempt to turn breech babies; could alter how nature or God had arranged them. One German midwife, Justine Siegemund, was caustic about colleagues who refused to intervene: ‘There are some midwives who do not think about what they are doing,’ she wrote, ‘and know no more and wish to know no more than how to receive a child when it falls into their hands and how to cut the navel string. They do not concern themselves with anything more, even violently dispute the possibility that a midwife can do anything more, because it is hidden from them.’ Here and there, midwives were beginning to picture what was hidden, and to deliver babies alive who might otherwise have come out in pieces.

In the early Enlightenment, new types of birth figures came into fashion. Authors of midwifery manuals and their illustrators didn’t simply copy the same old 15th-century German woodcuts, but produced fresh images using new observational techniques: Philippe Peu used ‘some small puppets’ to demonstrate foetal positioning to his draughtsman. Copperplate engraving permitted more detail. Birth figures came to reflect real cases that midwives had attended. Siegemund, who had learned her practice by studying books, was often asked to consult on complex labours. In her midwifery manual, she described a severely impacted arm presentation, and commissioned illustrations that represented exactly how she had managed, by removing its arm, to deliver the child.

In these later 17th-century birth figures, which depict the interventions of hands and arms and rods and string, wombs are no longer playrooms for acrobatic toddlers. Instead the reader of midwifery manuals is confronted with the close, contracting force of the body in labour; and shown, too, the incredible skill required to work with birth tools in the small and dynamic space of the womb. Extra details, such as placentas, membranes and buttocks, were included, lending a new reality effect to the images. Foetuses got serious about the work of being born: their smiles were replaced with grave little faces, sometimes turned away from the viewer or hidden behind tight fists. Birth figures showed what might be accomplished by a skilled midwife; and the impossibility, for those less skilled, of accomplishing such feats.

Male midwives attempted to resolve this tension with perfectly androgynous hands. In Hendrik van Deventer’s New Improvements in the Art of Midwifery (1728), his illustrator demonstrated how a male midwife might insert his hand in order to feel the shape or tilt of the womb; Cosme Viardel’s Observations on the Practice of Natural, Unnatural, and Monstrous Deliveries (1671) showed the delicate contortions and tractions that might be performed with the hands to deliver a breech birth safely. According to Deventer’s manual, the ideal male midwife had ‘slender Hands, long Fingers, and quick Feeling’. His arms were unnaturally bendy, his fingers freakishly jointed; the muscles of his forearm rippled with the strain of controlled effort. The midwife’s hand was a gender-bending invention of the Enlightenment, combining the intelligence and strength of a man’s touch with the sensitive delicacy of a woman’s.

This androgynous hand made the visual argument that the foetus would be delivered alive and the woman would feel little pain. But I doubt these images would have convinced anyone with a cervix. In one engraving from Deventer’s manual, his arm is shown inserted into an empty uterus almost up to the elbow, the engraver’s close, texturing lines transforming his hand into a radiating light within a cavernous female darkness. These guys really thought that they were enlightening the womb, the last preserve of unreason, at least in Europe. Thomas Dawkes’s The Midwife Rightly Instructed (1736), written in dialogue, includes this exchange between a surgeon and a midwife, who has been instructed to remove the placenta manually:

MIDW: Well, but Sir, if I do this, I must be obliged immediately to commit the Child to some other Woman in the Room; and that is not a customary thing with us midwives.

SURG: True, Lucina, neither is it customary, with the generality of Midwives, to practice means that are consistent with Reason, and the Nature of Things.

The body is often analogised, and in the Enlightenment the analogy was mechanical. The body was a machine powered by the soul, and the mysteries of birth were no longer mysteries but physical laws that might be understood if a woman’s parts could be isolated, identified, diagrammed. Birth figures once depicted only soft flesh, but now paid close attention to the pelvis, the tailbone. How did it all fit together? How did a foetus rotate within the pelvis on its way out? A mechanical understanding of birth implied that touch was no longer enough; the imagination had to work harder. Deventer wrote that ‘a Midwife cannot altogether make a true Judgment by Touch, who does not know … how the Secret Parts of a Woman answer.’ Illustrations of foetal presentation became more technical, harder to read without a highly professionalised education. Enlightenment midwifery required feeling to be fortified by abstraction.

Forceps were mechanical hands invented to assist a mechanical body. An elite London family of emergency midwives, the Chamberlens, had invented forceps in the late 17th century and had been using them to assist in births ever since, but they remained a trade secret until Hugh Chamberlen publicised them in 1733. Emergency midwives studied Chamberlen’s book, tore out the engravings of forceps and took them to instrument-makers. It seemed that craniotomies might become a thing of the past. One midwife, William Smellie, called forceps ‘artificial hands’, a cyborg technology that allowed male midwives to transcend gender and the impropriety of touching a woman’s body.

Not everyone liked them. Female midwives, disbarred from using them, thought forceps were brutish and dangerous; even some male midwives feared that forceps were damaging to both mother and foetus. William Douglas wrote in a rejoinder to Smellie that ‘such monstrous Hands are, like Wooden Forceps, fit only to hold Horses by the Nose, whilst they are shod by the Farrier.’ Tories were Instrumentarians and supported the progress of Reason and Science represented by forceps; Whigs were Deventerians, valuing manual intervention over tools. Women hated forceps, so emergency midwives took to smuggling them into the birthing chamber. Smellie advised hiding them in a pocket and then under a sheet, so that a midwife ‘will often be able to deliver with the forceps, without their being perceived by the woman herself’. A farrier was at least straight with his horses.

Some women chose death rather than have a forceps-assisted delivery. In his midwifery manual, Fielding Ould recounted the case of a labouring woman who ‘heard the clashing of Irons against each other, which terrified her prodigiously; and asking him what he was then going to do, he told her, that without having Recourse to the Help of Instruments, her Life was inevitably lost; which she absolutely declared she would not submit to, but chose rather to die.’ When I read this, I thought: Sure. I remember that serene welcoming-of-death feeling. It’s ridiculous, really; forceps are just a glorified pair of salad tongs. But if that’s all it takes to make you welcome your own death – how fragile one’s attachment to life turns out to be.

When Smellie came to produce his Sett of Anatomical Tables in 1754, he used foetal cadavers as puppets, arranging them in his studio for his draughtsman. The mid-18th century required a new naturalism and austerity of style, one that was borrowed from the anatomy theatre. William Hunter’s The Anatomy of the Human Gravid Uterus (1774), with its morbidly, extravagantly detailed drawings, was its culmination. Hunter included an anatomical drawing of the dissected body of a woman who died when nine months pregnant. Her legs are cut off mid-thigh, skin and muscle spread open, the foetus cramped in its hiding place, its skin desiccated from exposure to air. This is not an abstract image of the possibilities of labour; not a toddler wheeling round in the womb. When Hogarth went to visit Hunter’s anatomy theatre, he cried, ‘Good God … how Snugg compleat the Child lies, I defy all our Painters in St Martin’s Lane to put a child into such a Situation.’ But Hunter did. He reproduced in obsessive detail these specific, snug bodies: a woman and a foetus for whom things went terribly wrong.

These images have been understood as an achievement of modernity, the accurate representation of biological truth. But Whiteley argues that they have their own reality effect – naturalism and brutality are styles too – and anatomical drawings did not replace practical images that taught foetal presentations and interventions. The York midwife John Burton commissioned George Stubbs to draw birth figures for his new manual; Stubbs mostly painted portraits of horses, and the learning curve was steep. His foetuses are strange, suffering creatures, awkward and cramped and resigned to the fate of being born. Burton was sceptical about forceps and showed manual interventions instead. Whiteley argues that images like these are evidence that Hunter’s anatomical style, so often associated with the dawn of modern obstetrics, coexisted alongside more expressive images of midwives’ hands feeling in the darkness, grasping hold of a living creature.

Smellie’s Sett of Anatomical Tables includes an illustration of a foetus whose birth was fatally obstructed. The hook has rent its skull, revealing blackness inside. The midwife’s muscled hands have reached into the interior and placed two fingers inside the foetus’s mouth, demonstrating how to wrench it free. The foetus’s eyes are squeezed shut and its face is contorted in what we must believe is pain. In comparison, the foetus being delivered by forceps looks very alive, even relaxed. His face is turned towards us, eyes open and lips parted in mild surprise to have found his head clamped. The forceps themselves are disembodied, not held by human hands but tied loosely together with a pretty ribbon. There appears to be no pressure where metal meets flesh, no indents on the foetus’s skin, and the slim forceps slip cleanly inside the birth canal; there’s even a little room to spare.

The foetus caressed by forceps points with one chubby, dimpled finger to the instrument. He knows. He is a historical subject. He feels his body in history; he knows he is a creature not of the womb, not of woman, but of the Enlightenment. He knows that, thanks to progress and the professional skill of the highly educated male midwife, he will part alive from his irrelevant mother. Is that meant to be enough? ‘At least you’re both healthy!’ people said to me after my son was born and I had told a bit of the story. But what about the fear? The elegance of forceps is early modern but the fear is both specifically historical and wildly timeless. One of the common symptoms of birth trauma is a confused sense of time: flashbacks, memories that feel as if they’re actually happening; in other words, a past that refuses to stay in the past. Birth can fold history in on itself. Maybe it’s helpful to call that trauma. Or maybe birth is the ordinary, exceptional feeling of being a body in history.