HOUSE OF THE DRAGON BLOODY CESAREAN SECTION: A DOCTOR’S PERSPECTIVE

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(SPOILER ALERT – CONTAINS PLOT REVELATIONS FROM HOUSE OF THE DRAGON, SEASON 1 EPISODE 1) Twenty million people tuned in to watch the first week of HBO’s House of the Dragon (the Game of Thrones prequel). The first episode contained a gory scene of an awake Cesarean section. Queen Aemma was in the process of giving birth to a male heir, the baby was presenting feet first (breech), and was stuck,and could not be delivered vaginally. Grand Maester Mellos (a medieval physician-equivalent) offered a potential solution to the king. He said, “During a difficult birth, it sometimes becomes necessary for the father to make an impossible choice. To sacrifice one, or to lose them both. There is a chance that we can save the child. A technique that is taught at the Citadel—which involves cutting directly into the womb to free the infant. We must either act now or leave it with the gods.” Soon after that conversation a knife descended as Mellos cut into the queen’s abdomen while she screamed and the king whispered into her ear that he loved her. The blood loss from the procedure left the queen dead from hemorrhagic shock. On the day following the broadcast, social media erupted at this non-consensual torture waged against the mother.

From a doctor’s perspective, could this fictional scene really have happened centuries ago? It’s a fact that cutting a child out from his mother’s womb was a death sentence for the mother in an era prior to the discovery of anesthesia and prior to the discovery of surgical techniques to control bleeding and infection. In the real history of our world, it’s unlikely any husband or family was offered the choice whether to sacrifice the birthing mother to save the child. Most Cesarean sections were done because the mother was already dead and cutting into the womb was a last gasp measure to save the child’s life. As House of the Dragon depicted, in primitive times there was no way to stop the acute bleeding from Cesarean incisions into the abdomen and the uterus. 

Cutting a child out from the uterus has been called a Cesarean section for centuries. Julius Caesar himself was not born from the procedure, as his mother did not die during his childbirth—she lived until Caesar’s mid-40s.  Cesarean section did have a significant role in a Shakespeare tragedy other than Julius Caesar.  In Shakespeare’s Macbeth the witches’ prophecy was that “. . . none of woman born/ Shall harm Macbeth.” (Act IV. Scene i) The Scottish nobleman Macduff was “from his mother’s womb/ Untimely ripped.” (Act V. scene vii) That is, Macduff was born by Cesarean section, and not naturally born of woman. Macduff eventually killed Macbeth in battle. 

The first known Cesarean section in which both the mother and child survived was performed in Prague in 1337.  The first successful Cesarean section to be performed in the United States took place in Virginia in 1794. Nonetheless, in Great Britain and Ireland in 1865 the mortality for Cesarean section was 85%. 

The medical advances that enabled nearly all women to survive Cesarean section were: 1) the discovery of sterile surgical practices of handwashing and antisepsis to prevent postoperative infections; 2) the discovery of surgical techniques to stop bleeding; and 3) the discovery of anesthesia.

Sterile surgical procedures began when Dr. Ignaz Semmelweis, a Hungarian physician, noted in 1847 that fewer women died from post-surgery fever if surgeons washed their hands. Years later Dr. Louis Pasteur and Dr. Joseph Lister provided evidence to explain germ theory. Dr. Lister’s principles of antiseptic care led the way to asepsis, which was the complete elimination of bacteria during surgery. 

Until the 1870s Cesarean section surgical technique to control bleeding remained crude, and did not include surgical suture closure. In 1882 the German obstetricians Dr. Adolf Kehrer and Dr. Max Sänger developed methods for preventing uterine bleeding by using suture (stitches) to close the wound

Prior to the discovery of general anesthesia, sedation for surgery usually included oral alcohol drinks, or opiates derived from poppies. General anesthesia was discovered in October 1846, when Dr. William Morton gave a public demonstration of inhaled ether use at the Massachusetts General Hospital in Boston. One year later, James Simpson, a Scottish obstetrician, administered ether to relieve the pain of childbirth for a woman with an abnormal pelvis. In 1853 Dr. John Snow gave Queen Victoria the inhaled anesthetic chloroform to relieve labor pain during the birth of her eighth child.

A modern Cesarean section is most often done under a spinal or epidural anesthetic. The anesthesiologist injects a local anesthetic drug into the mother’s low back to render her numb from the level of her nipples to her toes. Under this regional anesthetic, a mother can be awake to bond with her infant minutes after the child is born. In emergency circumstances, general anesthesia may be required for Cesarean section. In these situations, a general anesthetic drug such as propofol is injected into the mother’s intravenous line, rendering her unconscious within 20-30 seconds. The anesthesiologist then inserts an endotracheal breathing tube into the mother’s windpipe (trachea) to ensure that oxygen and anesthesia gases are delivered directly and safely into the lungs, and at the same time eliminating the risk of stomach contents regurgitating into the mother’s lungs.

In the United States today, Cesarean deliveries comprise a stunning 1/3 of the total number of births. Attempts to reduce the rate of Cesarean sections have been largely unsuccessful because of the perceived safety of the operation, the medical-legal climate, and maternal requests for Cesarean sections. Cesarean sections carry a higher maternal mortality risk compared with vaginal birth. In a retrospective study of 1.5 million deliveries between 2000 and 2006, the rate of maternal death was 0.2 per 100,000 for vaginal births, and 2.2 per 100,0000 for Cesarean deliveries.  

Cesarean sections in the United States today are typically controlled surgeries, with comfortable mothers and with the father present in the operating room holding the mother’s hand. Expectant mothers can be reassured that because of advances in anesthesia and surgery, the pain, horror, and lethal outcome from a Cesarean section as depicted in the House of the Dragon will not occur in the modern world of medicine.

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