The Vaginal Seeding Debate

Abstract

 This paper examines the debate between implementing artificial maternal-neonate microbiota transfer post cesarean section via a process known as vaginal seeding and foregoing the procedure in exchange for other well studied methods of establishing the fetal microbiome.

The Debate

Science of the human microbiota (or more commonly referred to as “microbiome”) is making a buzz in the medical world. The current widespread scientific belief is that the symbiotic relationship between humans and certain microbes is responsible for healthy immune and metabolic function, and this colonization of the microbiota is established during VD (vaginal delivery), transferred from mother to offspring. Babies delivered via CSD (Cesarean section delivery) are not exposed to the mother’s normal vaginal biota. Vaginal seeding is a solution to this aberration in neonatal microbiome inoculum. It is a relatively simple process in which fluid from the mother’s vaginal canal is collected with sterile cotton gauze. The fluid is then swabbed onto the skin, mouth, and nose of a cesarean section neonate within the first hours of life. This project will evaluate the issue of vaginal seeding and whether or not it should be indicated in the introduction of beneficial, symbiotic microbes to the newborn. It will examine pertinent background information and propose the solutions of: a) implementing vaginal seeding versus b) foregoing vaginal seeding for established alternatives and suggest which solution is most ideal.

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What is Vaginal Seeding?

As of late, modern science has developed a crisper image of the concept, implication, and impact of the complex human-microorganism relationship. The sum total cellular mass of a human being is actually more non-human than human. Recent estimates place the ratio at 10:1 foreign to human cells (). These microorganisms include bacteria, fungi, protists, and viruses that live in harmless conjunction with our normal human physiology.() They exist on our skin, hair and within our GI tract, vaginal canal, and other mucus membranes. How is this colonization of microbes first introduced? Due to the mother’s immune system, we develop within what we presume to be a uterine environment free of any foreign cells (Mueller 2014). Therefore, the fetus’ first interaction with any non-self microbes begins when it enters the mother’s vaginal canal. It is here that a maternal-neonatal exchange of microbiota occurs and is facilitated by the birthing process. As the fetus is forcefully pushed through the vaginal canal it is bathed in maternal biofluids brimming with healthy and/or pathogenic microbes. So, with this thinking, what about cesarean births? These babies, surgically delivered via aseptic sterile technique through the mother’s abdominal wall, are essentially denied this natural inoculation process from mother’s microbiome. In recent years, an intervention known as VS (vaginal seeding) has been more increasingly implemented on post-cesarean newborns. This noninvasive procedure coats the skin and mucous membranes of the neonate with the collected vaginal secretions of the mother. Scientific evidence suggests this process isn’t entirely necessary to transfer healthy microbes. The idea that the birth canal provides the initial conduit for establishment of fetal microbiome has been challenged. Evidence of microbial cells living in the uterus, placenta and umbilical cord have been identified leading scientists to believe that the fetal microbiome is established before birth thus rendering the idea of VS obsolete (Mueller 2014). Experts argue that VS could in fact provide more harm than good in that it can transfer harmful undiagnosed pathogenic bacteria and viruses including gonorrhea, human papillomavirus, group A streptococci to the neonate from the mother (Splete 2017)

The Advantages of Vaginal Seeding

In the age of information patients become better informed and thus more and more prospective parents are requesting that their OB/Gyn perform VS on their newborn in the instance of cesarean section (Splete 2017). So, why would mothers and healthcare providers want to do this in the first place? Babies born vaginally exhibit higher counts of vaginal bacteria Lactobacillus species such as L. crispatus, L. gasseri, L. jensenii, and L. iners. (Stinson 2018) In the very first VS study, Maria G. Dominguez-Bello, Ph.D., of New York University was able to create microbiomes in 18 CSD (cesarean delivered) neonates that resemble that of VD neonates (Smith 2016). Studies have shown that babies born via CSD have a greater risk of developing allergic disorders, obesity, and asthma and thus a lifetime of sequelae. There is a correlation between reduced instance of these disorders and colonization of immune-system modulating healthy gut biota (Scoop 2019). There is a fear that if the neonate is not immediate colonized by the mother’s healthy microbiota, then the ambient microbes of the surrounding environment, such as the hands of parents and caregivers, and the surfaces of the hospital room, will take over instead. These environmental microbes may not have the same benefits as the mother’s and could possibly be pathogenic (scoop 2019). VS is still not a mainstream practice amongst obstetricians as the science is very new. There is always a lag between scientific discovery and mainstream implementation. Interestingly and not surprisingly, there is also a sexist barrier to the lay acceptance of vaginal seeding. There is a societal construct that the naturally occurring secretions of woman’s vagina are unclean, dirty, or “gross” (Lokugamage 2019). The feminist desire to have complete bodily autonomy and to make a well informed decision regarding VS as a health choice for herself and her newborn may be hindered by embarrassment. It may be difficult to ask for this procedure or discuss it with loved ones. Normalization of women’s bodies and their natural life giving and sustaining functions will aide in the integration of procedures such as VS in conversations right alongside skin to skin therapy and delayed cord clamping. In the all too recent past even discussing the concept of skin to skin therapy was considered new age and unconventional, now it is a widely accepted practice.

Foregoing Vaginal Seeding

Regardless of the scientific data promoting its benefits, many health practitioners are not willing to perform VS on their patients and their reasoning falls on a simple benefit vs risk analysis. Many doctors would prefer to implement microbiome preserving practices and procedures that are well established, evidenced based and proven safe on CSD neonates. These include such interventions as a 12 hour delay of the newborn’s first bath and immediate breastfeeding and skin to skin contact in the delivery suite (Smith 2016) There is data that indicates that there is no difference between the microbiome’s of VD versus CSD infants and it is the use of antibiotics during the birthing period that negatively affects microbiome, not the method of delivery (obesity, fitness, and wellness week 2016). It is standard practice to administer IV antibiotics with every Ceserean delivery and in vaginal delivery where mothers have an active infection or who have been identified as carriers of group B hemolytic streptococcus aureus. Group B strep is a bacterial pathogen that can be a member of the mother’s natural microbiota, but deadly to the newborn. Other factors such as breastfeeding duration, onset of labor, BMI of the mother, and mother’s diet all play a role in the establishment of the fetal microbiome independently of vaginal delivery (Stinson 2018) Doctors also want to warn against the practice of VS because it is so incredibly simple, women could do it at home and unknowingly cause harm to their newborn. If a mother forgoes prenatal care and is not prescreened for potentially harmful infections such as gonorrhea, chlamydia or group B strep and implements VS at home after being discharged from the hospital, she could put her infant’s life at risk. (Smith 2016) It is because of this potential transference of pathogenic microbes that the American Councel of Obstetritians and Gynecologists does not formally recommend VS (Splete 2017).

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Given the conflicting arguments of pro versus anti VS, a decision is a difficult one. Parents and healthcare providers want to provide the best for infants, and do not want to sacrifice a healthy microbiome which could have a lifetime of implications in exchange for CSD if they don’t have to. Vaginal seeding appears to be the best choice given certain circumstances: the mother is pre-screened for pathogenic organisms that could harm the newborn, and the procedure is done under the supervision of a physician (Scoop 2019). The procedure is incredibly simple, requires very little time and no extra cost. Screenings for GBS and other such harmful bacteria or viruses are already established practice in pre-natal care. It is the responsibility of health care providers to lessen the negative impact of certain interventions and surgical procedures such as CSD if there is a simple, low cost option such as VS which is proven safe if the right measures are taken to ensure that the neonate will not be exposed to harmful pathogens. VS is arguably a brilliantly easy solution to a complex problem.

References

• Haahr, T, Glavind, J, Axelsson, P, Bistrup Fischer, M, Bjurström, J, Andrésdóttir, G, Teilmann‐Jørgensen, D,Bonde, U, Olsén Sørensen, N, Møller, M, Fuglsang, J, Ovesen, PG, Petersen, JP, Stokholm, J, Clausen, TD.Vaginal seeding or vaginal microbial transfer from the mother to the caesarean‐born neonate: a commentary regarding clinical management. BJOG 2018; 125: 533– 536.
• Lokugamage, A.U., and S.D.C. Pathberiya. "The microbiome seeding debate - let's frame it around women-centred care." Reproductive Health, vol. 16, no. 1, 2019. Gale OneFile: Health andMedicine, http://link.galegroup.com/apps/doc/A592926870/HRCA?u=uiu_henderson&sid=HRCA&xid=130f8478. Accessed 29 July 2019.
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• Splete, Heidi. "ACOG advises against vaginal seeding." OB GYN News, Dec. 2017, p. 3. Gale OneFile:HealthandMedicine, http://link.galegroup.com/apps/doc/A521591784/HRCA?u=uiu_henderson&sid=HRCA&xid=4242bd3a. Accessed 29 July 2019.
• Stinson, L. F., Payne, M. S., & Keelan, J. A. (2018). A Critical Review of the Bacterial Baptism Hypothesis and the Impact of Cesarean Delivery on the Infant Microbiome. Frontiers in Medicine. Retrieved from http://link.galegroup.com.uiulibrary.idm.oclc.org/apps/doc/A537346998/HRCA?u=uiu_henderson&sid=HRCA&xid=17ecd72b
• "Swabbing cesarean-born babies with vaginal fluids potentially unsafe and unnecessary." Obesity, Fitness & Wellness Week, 16 June 2018, p. 6661. Gale OneFile: Health andMedicine, http://link.galegroup.com/apps/doc/A542029824/HRCA?u=uiu_henderson&sid=HRCA&xid=646783f5. Accessed 29 July 2019.
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