Dr. Thais Aliabadi—or Dr. A as the Kardashians call her—is a famous OBGYN in Los Angeles, practicing at Cedars-Sinai Medical Center. I have seen her on many TV shows, like Keeping Up with the Kardashians and Dr. Phil, and liked way too many Instagram posts that raved about her practice. She was kind enough to spare a few minutes from her INCREDIBLY HECTIC schedule (I've seen it first hand) and answer my followers' frequently asked questions.
NS: Young women or first time pregnant moms really fear tearing–some even ask for elective C-sections for this reason. Can you explain to us if and when tearing happens, and the different levels of tearing?
Dr. A: Tearing is more common with first time moms, because once you have a child the vagina stretches, and the perineum, which is the opening to the vagina, also stretches. As it stretches, with the second and third baby, as long as its done in a controlled manner in the hands of an experienced OBGYN there is much less tearing. A lot of second and third time moms won’t even tear.
In my experience, and I’ve done a lot of deliveries, every patient is different. You can sometimes have a 6-pounder (baby) that comes out and the mom tears, and you can have first time moms that deliver 9-pounders and they don’t tear. It has to do with the size of the baby, and with the way the baby presents itself—some babies come with the hand next to their head, so as you’re pulling and delivering the arm, the elbow sometimes causes a tear.
The length of time that the head is sitting in the vagina also makes a difference. Patients who are in labor for many hours where the baby's head sits in the vagina, will experience swollen labia. As you get more edema your tissue breaks and tears easily.
It also 100 percent has to do with the experience of the doctor delivering the baby. During the delivery of the head, we have one hand on the baby’s head and with the other hand we are supporting the perineum; we try to squeeze it to prevent the head from popping out. If you do a slow delivery, you decrease the risk of tearing.
Sometimes you do all that and it still tears! If you push a big baby out you’re more likely to tear than pushing a small baby out. If you’re using a vacuum, you’re more likely to tear. But
patients get concerned about vaginal birth not necessarily because of the tearing—with a C-section you get a bigger cut—but the stretching of the vagina, the laxity of the vaginal wall that remains after childbirth. Think of the vagina as an elastic band that you pull—you pull it once, it goes back to normal, you pull more, it doesn’t get back to its original position. The more you stretch it, the less it goes back to its normal state.
Stretching has to do with the patient’s tissue too; there are patients who have had four kids and their vaginal walls are very well supported. And there are patients who push a 7 pounder out and they have prolapse. It's genetic.
NS: Is there a way to prevent this stretching?
Dr. A: You can do pelvic floor exercises, but at the end of the day it is how much that tissue gets stretched, how long the baby sits in the vagina, and how much your tissue goes back. Think of stretch marks on the abdomen—some women give birth and a couple of months later they are flat, their skin is great, and some women get stretch marks; you can’t prevent that. We all have different tissue, different healing.
NS: How do you fix vaginal tears?
Dr. A: We are very good at putting back the laceration and the tearing. We put stitches in and all the patient has to do it to keep it clean. We don’t have to touch the sutures, we don’t have to pull them, they just dissolve. It takes six weeks for any wound in the body to heal, so you just give it six weeks. The first week they are sore, but after a week they are good to go. C-section is a lot more painful.
NS: I saw Lilly Ghalichi shared a squirting bottle in her Instagram stories and said that she has to squirt water to her vagina every time she uses the bathroom because she tore during birth. What does that mean?
Dr. A: That squirting bottle keeps the wound clean, especially when you urinate. Sometimes it burns as it runs through the incision. Especially with vaginal birth it burns a lot, so you can squirt water on it and it helps.
NS: What's the difference between a vaginal tear and a cervical tear?
Dr. A: Cervical tears are extremely rare. Cervix is the mouth of the uterus, and it needs to dilate to 10 centimeter and thin out 100% before you’re ready to push. Some patients, when they don’t have an epidural, are in so much pain that even when their cervix is 8-9 cm they have that urge to push. And when they start pushing early they can cause lacerations on the cervix. That’s deep inside the vagina and difficult to repair, but extremely rare.
NS: Are epidurals common in your practice?
Dr. A: Yes. Over 98 percent of my patients get an epidural.
NS: When is an episiotomy performed? How often do you perform it? (Episiotomy is a controlled cut to the vagina to prevent uncontrolled tearing that can be harder to heal)
Dr. A: Not even once a year. I only cut if it’s an emergency and I need to delivery the baby, which is rare. It used to be common practice, but I don’t cut because at least 50 percent of my patients don’t even tear with the first baby. I just let the baby come out. When you cut an episiotomy, you’re already guaranteed a second degree tear. When you deliver a big baby it will take it to a third or fourth degree.
NS: What are some things we can do to prepare for pregnancy, before we even conceive?
Dr. A: Being healthy is the best thing you can do. Having a good exercise routine, a good diet. No alcohol, no smoking, no drugs. Do a check-up with your primary care physician or OBGYN to do a full blood panel and liver panel. Make sure your immunizations are up to date. Get genetic testing done for recessive genes that checks the parents for 200+ diseases they can pass to their children. Couples can get tested for that. Take at least 3 months of prenatals and folic acid prior to starting pregnancy.
Overweight? Lose the extra weight. High blood pressure? Fix it before you get pregnant. On medication for depression? Switch to a prescription you can stay on during pregnancy.
NS: I know that age 35 and above puts you in the "high risk" category for pregnancy. Millennials are postponing marriage and kids more than any other generation before them—does the 35-year cutoff still hold?
Dr. A: The 35 year old age putting you in higher risk for pregnancy is valid. Our egg reserve starts going down when we are teenagers, and we lose eggs until we are menopausal. We are born with millions but by the time we are menopausal we have about 1000 left. The quality goes down too. Once you start getting to your mid 30s the quality of the egg is getting affected. If you have other conditions like endometriosis, they can predispose you to a lower egg quality and quantity in your mid 30s. I check my patients’ egg reserve at 30 and encourage egg freezing by 32. Most people say by 35 is okay but you have to remember it’s such an expensive process, the sooner you do it the more eggs and better quality of eggs you get out.
As we get older, advanced maternal or paternal age, egg and sperm quality go down, and we are more likely to have miscarriages, more likely to have pregnancies with chromosomal abnormalities. So when I have patients who are older and they keep pushing it I definitely do an egg reserve testing—but this only tests the quantity and not the quality, so they have to know that after 35 they start gambling, cause there is no guarantee.
Once you have one kid then you can wait all you want, cause your whole system has been tested. But until you have that first child you have to be careful, because 10 percent of couples don’t get pregnant after actively trying for a year.