The horrifying truth behind Gladys’ childbirth in The Gilded Age season 4 premiere

*Warning: Spoilers ahead for The Gilded Age season 4 premiere*

It’s touch and go for Gladys Russell in The Gilded Age season 4 episode 1, with her husband Hector Vere forced into making an impossible decision: save his wife or his child. 

Despite pressure from his sister Lady Sarah Vere (Hattie Morahan), the Duke of Buckingham (Ben Lamb) tells the doctor: “Save them both if you can. But if a choice must be made, then save the Duchess.”

If you recall, Gladys (Taissa Farmiga) revealed at the end of The Gilded Age season 3 that she was pregnant. The season 4 premiere, titled ‘Ring the Bells’, jumps forward by around nine months as Gladys is giving birth. 

And the labour is anything but straightforward. Gladys is in a lot of pain, and the doctor reveals that the baby is in breech – meaning they’re positioned feet or bottom first rather than head first. 

That’s when Hector makes the difficult decision. Thankfully, Gladys is able to give birth to a healthy baby boy. Gladys appears to drop off to sleep, but housemaid Adelheid Weber (Erin Wilhelmi) realises she’s haemorrhaging.

The doctor steps in and saves Gladys’ life – but in order to do so, he has to remove Gladys’ uterus. So while she doesn’t die, this means she’ll no longer be able to conceive another child. 

It’s worth noting that The Gilded Age is set in 1886, and takes inspiration from real historical figures and events. And while Gladys’ ordeal might seem particularly brutal, the reality of childbirth at the time was just as horrifying.

How dangerous was childbirth in the 1880s?

In short, it wasn’t like it is today. Although achievements in medicine had made childbirth safer by the late 1880s, it was still a potentially deadly experience for both the mother and the baby.

According to historical research published in Medical History, around four to five women died from pregnancy and childbirth-related causes for every 1,000 births in 19th century England. Or, around one in every 200 to 250 births.

And things weren’t much better across the Atlantic. Reliable US figures for 1886 aren’t available as the government hadn’t set up a tracking system yet. But the CDC estimates that at the beginning of the 20th century, between six and nine American women died from pregnancy-related complications for every 1,000 births.

The statistics for babies are equally concerning. Between 1886 and 1890, around 145 out of every 1,000 babies born alive in England and Wales died before their first birthday. In the US, this figure was around 100 per 1,000.

To put that in perspective, in 2024, the US maternal mortality rate was 17.9 deaths per 100,000 live births. And the UK’s was 12.8 per 100,000 between 2022 to 2024. Infant mortality has dropped to 5.5 deaths per 1,000 live births in the US and 3.9 in England and Wales.

So why was childbirth so dangerous back then? Well, for one thing, doctors had no antibiotics to treat infections. And severe blood loss was incredibly difficult to manage without blood transfusions. Although anaesthesia had been introduced decades earlier, major surgery remained far riskier than it is today.

Breech births, like Gladys’, made things even scarier. If the baby’s body emerged before its head, the head could become trapped, cutting the baby’s oxygen supply. Doctors had far fewer options for safe intervention. 

But perhaps the most horrifying part of Gladys’ ordeal is the operation that ultimately saves her life.

You see, in 1876, Italian obstetrician Eduardo Porro pioneered a procedure involving the removal of a woman’s uterus following a caesarean delivery. According to an 1884 report, out of 152 of these operations, 86 mothers died – a mortality rate of more than 56 per cent.

It’s worth noting that prior to this, cesarean sections had a maternal mortality rate of nearly 100 per cent. So for the time, this was a huge improvement. But nowadays, it’s hard to look at those stats in a positive way. 

Gladys doesn’t undergo this exact procedure in season 4 of the HBO series, as she delivers her baby before the hysterectomy. Even so, this shows just how dangerous major surgery could be at the time.

And while the operation saves Gladys’ life, she now has no idea that she’s lost the ability to have more children. In fact, she was kept in the dark every step of the way. 

Why Gladys was kept in the dark about her own body

Even when women survived in the 1800s, they often had little control over the decisions being made about their own bodies.

At the time, doctors often worked under a “paternalistic framework” – essentially, it was their responsibility to decide what was best for the patient. And married women were legally and socially subordinate to their husbands, meaning the men would receive information about their health – rather than the female patients themselves. 

This didn’t mean women had no legal rights to make medical decisions, or that every doctor behaved this way. But the idea of informed consent as we understand it today was still a long way off.

For Gladys, not only has she undergone an operation that means she’ll never be able to have another child, but she isn’t even the first person to find out. Speaking to TVLine, Carrie Coon, who plays Gladys’ mother Bertha Russell, addressed this. 

“It’s wild, the gatekeeping of information, how a woman wouldn’t be entitled to information about her own body [and it] has to be delivered through her husband,” she said. “It’s wild that you don’t have that conversation with a doctor.”

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Featured image credit: HBO