From Fetus to Child

An Observational and Psychoanalytic Study

Alessandra Piontelli

• Éditeur: Routledge
• Année: 2003
• ISBN:
  9781134905348
• Édition: 1
• Sujet: Psychologie
• Sous-sujet: Psychanalyse

The use of ultrasonic scans in pregnancy makes it possible to observe the fetus undisturbed in the womb. Dr Alessandra Piontelli has done what no one has done before: she observed eleven fetuses (three singletons and four sets of twins) in the womb using ultrasound scans, and then observed their development at home from birth up to the age of four years. She includes a description of the psychoanalytic psychotherapy of one of the research children, and the psychoanalysis of five other very young children whose behaviour in analysis suggested that they were deeply preoccupied with their experience in the womb.

Dr Piontelli has discovered what many parents have always thought - that each fetus, like each newborn baby, is a highly individual creature. By drawing on her experience as a child psychotherapist and psychoanalyst as well as on her observational research, she is able to investigate issues relating to individuality, psychological birth and the influence of maternal emotions during pregnancy. Her findings demonstrate clearly how psychoanalytical evidence enhances, deepens and supports observational data on the remarkable behavioural and psychological continuities between pre-natal and post-natal life.

1
Fetal behaviour and fetal environment

My aim in this chapter is to provide some basic information for those psychoanalysts and lay readers who are interested in these areas of research but have little time for deepening them.

When approaching the field of fetal mental life, one has to rely principally on data made available by medicine and biology in order not to fall into the realms of pure imagination and wild speculation. Though there is more to the mind than simple movement, it is mainly through the somatic manifestations of the fetus that one could hope reasonably to infer something about its possible mental functioning.

Within the vast realm of medical and biological research, I will refer in particular to investigations in the field of fetal behaviour as it can be observed with ultrasounds. In pursuing my interest in the beginnings of mental life, I decided to concentrate mainly on the study and observation of fetal motor-behaviour, both because this was more easily accessible to my direct experience and did not require extremely specialized skills and because it was also closer to my previous practice of observing infants and young children. In Infant Observation too one has to rely mostly on overt behaviour to infer the mental and emotional experiences of the baby, as movement is seen to represent a means of communication with its physical and human surroundings.

Moreover, through motility fetal perceptions can also be investigated indirectly, as perceptual mechanisms are often associated with particular motor mechanisms and their output can only be observed after it has activated some kind of motor response. Central mechanisms too can be ‘seen’ in action in the coordination and activation of various motor mechanisms. Therefore, through motion one can deduct important information about sensory and higher functions of the brain. Selected findings on these will be also reviewed in this chapter.

These areas of research have now become extremely specialized and incredibly extensive. I will therefore only be able to give a rather superficial outline of them. One could too easily get lost in the meanders of histology, neurophysiology, or neurochemical transmission and all too far removed from the macroscopic interest of the psychoanalyst in the anfractuosities of the mind.

Contrary to many popular beliefs, no fetus develops in pure isolation and its behaviour is also a reflection of the interaction with its pre-natal environment. Hence at least a rough knowledge of some of the characteristics of the fetus's habitat is also essential for the comprehension of fetal actions and reactions. Therefore, after discussing in some detail fetal movement and the sensations and stimuli reaching the fetus, I will try to describe briefly certain aspects of intra-uterine environment.

These areas of research are rapidly and continuously expanding and therefore by the time this book is published it may well be that other findings will have become available and some of those mentioned here may have already become obsolete. I hope, however, that my indications will be useful to readers and will stimulate their desire to deepen their knowledge in this fascinating field.

Fetal motility

Early investigations

Fetal motility began to be investigated scientifically only towards the end of the last century, and, before ultrasounds were introduced, several techniques were used to study it.

On the one hand one had the possibility of relying on the direct palpation of movements through the maternal abdominal wall often accompanied by auscultation with a stethoscope. Particularly important and incredibly ‘modern’ were the observations and intuitions of Preyer. As early as 1885, he wrote in his classic book Spezielle Physiologie des Embryos that fetal movements started probably long before the twelfth week of pregnancy and he considered fetal motility to be spontaneously generated and not a mere response to outside stimuli. He believed that the movements to be seen in the newborn were similar to those of the fetus and he recognized the abnormality and excess of movements of deformed fetuses. He also described fetal drinking of the amniotic fluid. All this was to be confirmed by the advent of ultrasounds, as, for instance, the onset of spontaneous motility was seen to start at 7.5 weeks post-menstrual age (Ianniruberto and Tajani 1981; de Vries et al. 1982), and sucking and swallowing movements have now been clearly visualized.

Generally speaking, though, apart from several brilliant but unverifiable intuitions, such studies permitted only a rough estimate of the quantity of clearly perceptible movements during the later stages of pregnancy.

More detailed observations were obtained through the study of non-viable aborted fetuses, particularly through the observation of their responses to various kinds of stimulation. Several observations were derived from such studies. In 1928 Minkowski described the spontaneous and induced motility of pre-agonic aborted fetuses from the second month of pregnancy. More recently Hooker (1952) and Humphrey (1978) continued along the same line of research and examined elicited movements in detail. The critical condition of the observed fetuses, though, rendered these observations less reliable when it came to formulating principles about the physiological condition of the fetus.

The same applied to many pioneering studies on lower animals (Carmichael 1933; Coghill 1929; Kuo 1932; Windle 1940), with the obvious added difficulty of drawing information from different species. Moreover, an interest in the origins of reflexes and neuromuscular development prompted these researches. Though these studies were certainly very thorough, these authors held the view that reflexes represented the fetus's earliest neural functions and that fetal movements were only induced by external stimulation. Many spontaneous movements were in fact only visualized later with the advent of ultrasounds and their contemporaneity with movement patterns elicited by stimulation was then observed. We can now state almost with total certainty that fetal motility is endogenously generated and not a mere response to external stimulation (Prechtl 1984, 1989).

Fetal motility was also investigated in premature infants particularly by Gesell (1945) and by Saint-Anne Dargassies (1966). Gesell noted that the ‘fetal-infant’ remained ‘true to its fetality’ even though born before its time and Saint-Anne Dargassies noted that neurologic maturity was primarily related to gestational age and not weight.

Another means of obtaining information on fetal movements was to rely upon accounts from mothers of their sensations. Several researchers, such as Walters (1964), Edwards and Edwards (1970), and Sadowsky et al. (1979), recorded and classified movements perceived by mothers. The first fetal movements (quickening) are usually perceived around the sixteenth week. Their presence was found generally to be a sign of well-being of the fetus, while their disappearance or diminishing below a certain frequency, a phenomenon described as ‘movement alarm sign’, was found to be connected with fetal distress (Sadowsky and Yaffe 1973).

All these methods, though clinically useful, had the disadvantage of being highly subjective and could not, for obvious reasons, be applied to the early stages of pregnancy.

Ultrasonographic investigations

A real breakthrough in the study of fetal motility and of fetal life in general was represented by the advent of ultrasounds, as they permitted the observation of the undisturbed fetus within its natural environment.

Ultrasonographic observations were described for the first time in 1971 by Reinold, who observed fetal movements between eight and sixteen weeks post-menstrual age. (It should be remembered that while embryologists when speaking of embryonic or fetal age refer to conceptional age, it is now common practice in obstetrics to refer to gestational or post-menstrual age, as for the patient it is usually much easier to remember the first day of her last period rather than the supposed date of conception.) Reinold classified fetal movements into two groups: (1) strong movements involving the whole body, and (2) slow movements limited to fetal parts. A similar classification was made by Juppila in 1976. In the meantime technological advances brought ever clearer and more detailed images. In 1980 Van Dongen and Goudie described a more detailed study on the progression of movements between seven and twelve weeks. A classification of individual movement patterns was first developed by Birnholz et al. (1978) and subsequently by lanniruberto and Tajani (1981) and by de Vries et al. (1982).

Other authors (Manning et al. 1979; Roberts et al. 1979; Patrick et al. 1980, 1982; Rayburn 1980; Visser et al. 1982) concentrated on the study of movement during the later stages of pregnancy.

Spontaneous fetal motility emerges and becomes differentiated at a very early age. The first type of pattern, still unclear and hazy, seems to be represented by the transient class of the so-called ‘just discernible’ (de Vries et al. 1982) or ‘vermicular’ movements (Ianniruberto and Tajani 1981); small shiftings of the fetal contour lasting from half a second to two seconds which appear between seven and 8.5 weeks of gestation and disappear from the fetus's repertoire two weeks later. According to Prechtl (1989) the first visible movements appear at about 7.5 weeks and consist of slow flexion and extension of the vertebral column with passive displacement of arms and legs. The repertoire expands rapidly from ten weeks onwards (at ten weeks, for example, hand and face contacts, stretches, yawns, jaw opening and movements of the tongue can be observed; by twelve weeks hand and mouth contact, sucking and swallowing as well as fine finger movements can also be observed) until by fifteen weeks it can be considered almost completed.

No neonatal pattern can be considered to originate at birth, as the fetus has already the full repertoire of movements which will be found in the neonate. The only difference lies in the quality of movement, most probably because of the increased influence of gravity after birth. Besides movement, no other function is seen to originate at birth either According to Prechtl, the ‘impressive continuum of neural functions from prenatal to postnatal life’ is made possible by ‘the large set of pre-adapted functions which emerge through prenatal life, mainly during the first half of gestation’ (Prechtl 1984).

Different fetuses of the same gestational age, under normal conditions, show identical patterns of behaviour, though the quantity of movement can vary, within certain limits, from one to another. From the eighth week, within the range of its capacities, the fetus shows clear individual initiative and choice of movement (de Vries et al. 1988). The differences between individuals are considerable and seem consistent throughout pregnancy (Rayburn et al. 1983; Prechtl 1989). Each fetus has its own pattern of daily activity and such patterns appear to be unrelated to the time of the day in which the mother is awake (Rayburn 1982).

Purposeful actions were observed early during gestation by lanniruberto and Tajani (1981). Very frequently and very early on one can, for instance, observe fetuses introducing their thumbs into their mouths.

Some types of movement are observed only during limited periods of time in the course of pregnancy: apart from vermicular or just discernible movements, jerky movements can be observed only between the ninth and the twentieth weeks and scissoring and extension of the legs between the thirteenth and the twenty-fifth week.

Some quantitative changes also occur during gestation. General movements, for instance, increase in incidence from eight to ten weeks, and then reach a plateau and remain at this level for the first six months. Isolated arm movements, rotation of the head and sucking movements all increase gradually in incidence over the first half of pregnancy (Prechtl 1989). Breathing movements gradually increase until about thirty weeks and hiccups reach a maximum at thirteen weeks, then gradually decrease (Trudinger et al. 1980). The rate of changes in fetal position reaches a climax at thirteen to fifteen weeks, then, probably due to a question of space in the uterus, decline (de Vries et al. 1982).

When the integrity of the nervous system is impaired qualitative changes in motor patterns precede quantitative changes (Prechtl 1989). Changes in the quality of movement, such as their becoming slow and sluggish, are considered to be a poor prognostic sign. In some cases acute fetal distress causes an exaltation of motricity, and movements then become abrupt, forceful, and frantic. Since motor functions are usually spared for a long time even following substantial and irreversible damage to the nervous system, a normal motricity does not by itself rule out fetal distress or guarantee the integrity of the central nervous system. The presence, however, of an alteration in movement can generally always be linked to severe organic damage (Ianniruberto and Tajani 1982). Milani-Comparetti (1981) postulated that fetal distress, particularly if of a hypoxic nature, resulted not only in a decrease in movement, but also in a regression towards more primitive patterns.

Normal fetuses usually show some kind of activity within ten minutes of observation (Roberts et al. 1979). Natale et al. (1986) with twenty-four-hour ultrasonographic observations have calculated that the fetus is active during about 14 per cent of the time between twenty-four and twenty-eight weeks of gestation.

Ultrasounds have also made it possible to compare the subjective assessment by the mother with ultrasonographic recording of fetal movement (Gettinger et al. 1978; Sorokin et al. 1981). All studies showed that mothers felt less movement than detected by ultrasounds and that the variations between individuals were very pronounced. Though fetal movements were felt by the majority of women, there were some mothers who seemed to be quite insensitive to them (Hertogs et al. 1979).

Each fetal movement, whether large or small, after thirty-two weeks is associated with fetal heart rate (FHR) acceleration, and nearly every large acceleration is associated with fetal movements as seen with ultrasounds (Hon and Quilligan 1968; Sorokin et al. 1982; Rabinowitz et al. 1983).

Ultrasounds have rendered it possible to visualize other fetal activities such as hiccups (a frequent and unclear, though apparently not worrisome occurrence) and swallowing and micturition with subsequent changes respectively in the volume of the stomach (Vanderberghe and de Wolf 1980) and of the bladder (Campbell et al. 1973; Visser et al. 1981).

Healthy human fetuses, from the tenth week onwards, periodically perform breathing movements (Boddy and Dawes 1975). Fetal breathing movements are paradoxical in nature, the anterior fetal chest moving inwards and the abdominal wall outwards. Their incidence increases with increasing gestational age (Trudinger et al. 1980). Such movements are not perceived by mothers and are irregular, shallow, and episodic and show a considerable diurnal variation in frequency. Fetal movement was generally found to be present during the intervals of apparent fetal ‘apnoea’ (Marsal and Genser 1980).

Fetal eye movements have also been visualized (Bots et al. 1981; Birnholz 1981, 1985). Fetal eye movements begin at between sixteen and eighteen weeks (Birnholz 1981; Awoust and Levi 1984; Prechtl and Nijhuis 1983), and by twenty-three to twenty-four weeks rapid eye movements (REM) are seen to appear (Birnholz 1985, 1989).

Pre-natal movement plays a necessary role in the fetus's normal physical and behavioural development (Hofer 1981; Moessinger 1983): normal muscular, skeletal, neural, and behavioural development are all facilitated by fetal activity, whilst altered morphological and behavioural development are likely to be the consequence of grossly modified fetal behaviour (Smotherman and Robinson 1988). For instance, the periodic swallowing and expulsion of amniotic fluid was found to be relevant for the normal development of the lungs (Vyas et al. 1982) and regulating the quantity of the fluid itself (Prechtl 1984). Pre-natal breathing is considered to represent an important practice that facil...