The American College of

Obstetricians and Gynecologists

WOMEN’S HEALTH CARE PHYSICIANS

ACOG COMMITTEE OPINION

Number 725 • November 2017

Committee on Obstetric Practice

This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice in collaboration
with Kurt R. Wharton, MD, and Meredith L. Birsner, MD.

Vaginal Seeding
ABSTRACT: Vaginal seeding refers to the practice of inoculating a cotton gauze or a cotton swab with vaginal
fluids to transfer the vaginal flora to the mouth, nose, or skin of a newborn infant. The intended purpose of vaginal
seeding is to transfer maternal vaginal bacteria to the newborn. As the increase in the frequency of asthma, atopic
disease, and immune disorders mirrors the increase in the rate of cesarean delivery, the theory of vaginal seeding
is to allow for proper colonization of the fetal gut and, therefore, reduce the subsequent risk of asthma, atopic
disease, and immune disorders. At this time, vaginal seeding should not be performed outside the context of an
institutional review board-approved research protocol until adequate data regarding the safety and benefit of the
process become available.

Recommendations Because of the theoretical risk of neonatal infection,

The American College of Obstetricians and Gynecologists the pediatrician or family physician caring for the
(ACOG) makes the following recommendations: infant should be made aware that the procedure was
performed.
• The American College of Obstetricians and Gyne- • Although findings are mixed regarding associa-
cologists does not recommend or encourage vaginal tions between breastfeeding and the development
seeding outside of the context of an institutional of asthma and atopic disease in childhood, exclusive
review board-approved research protocol, and it is breastfeeding for the first 6 months of life has multi-
recommended that vaginal seeding otherwise not be ple known benefits and remains the recommendation
performed until adequate data regarding the safety of ACOG for all women who do not have physical or
and benefit of the process become available. medical conditions that prohibit breastfeeding.
• The American College of Obstetricians and Gyne-
• The paucity of data on this subject supports the need
cologists only supports the performance of vaginal
for additional research on the safety and benefit of
seeding in the context of an institutional review
vaginal seeding.
board-approved research protocol.
• Should a patient insist on performing the procedure
herself, a thorough discussion with the patient should The Infant Microbiome
be held acknowledging the potential risk of transfer- The human microbiome is the composite of genes of the
ring pathogenic organisms from the woman to the microorganisms (microbiota) living in and on the human
neonate. Risk stratification is reasonable for such body that influence the health and development of the
women in the form of testing for infectious diseases host (1). The gastrointestinal tract of the fetus is believed
and potentially pathogenic bacteria. Serum testing to be sterile. Bacterial transfer from the woman to infant
for herpes simplex virus and cultures for group B occurs during birth, skin-to-skin contact after birth, and
streptococci, Chlamydia trachomatis, and Neisseria breastfeeding. Bacteria function to ferment unused energy
gonorrhea should be encouraged. It is further recom- substrates, stimulate the immune system, prevent growth
mended that the obstetrician–gynecologist or other of pathogenic bacteria, regulate development of the gut,
obstetric care provider document the discussion. and produce vitamins for the host (2). Cesarean delivery,

e274 VOL. 130, NO. 5, NOVEMBER 2017 OBSTETRICS & GYNECOLOGY

antenatal and intrapartum antibiotics, and formula feed- significantly higher in the children born by cesarean
ing may interrupt the natural maternal-to-neonatal bac- delivery than in those delivered vaginally (adjusted odds
terial transfer during the critical early period of neonatal ratio [OR], 1.37; 95% CI, 1.14–1.63). Cesarean delivery
immune development. Commensal bacteria present in also was associated with subsequent diagnosis of asthma
breast milk and maternal areolar skin bacteria contrib- (OR, 1.24; 95% CI, 1.01–1.53); this association was gen-
ute to the early seeding of the infant gut. A prospective der specific, with a positive association restricted to girls
longitudinal study of 107 healthy infant and woman (OR for asthma in girls, 1.53; 95% CI, 1.11–2.10; OR for
pairs demonstrated that at 30 days, infants who were asthma in boys, 1.08; 95% CI, 0.81–1.43). Children born
breastfed to obtain 75% or more of their daily milk intake to women who had repeat cesarean deliveries had an
received a mean (SD) of 27.7% (15.2%) of the bacteria increased risk of developing allergic rhinoconjunctivitis
from breast milk and 10.3% (6.0%) from areolar skin (OR, 1.78; 95% CI, 1.34–2.37). A similar increase was
(3). Although findings are mixed regarding associations noted for asthma in girls (OR, 1.83; 95% CI, 1.13–2.97)
between breastfeeding and the development of asthma but not in boys (OR, 1.08%; 95% CI, 0.81–1.43) born to
and atopic disease in childhood (4, 5), exclusive breast- women with repeat cesarean deliveries (7).
feeding for the first 6 months of life has multiple known A retrospective review from the Danish Medical
benefits and remains the recommendation of ACOG for Birth Registry and the Danish National Patient Registry
all women who do not have physical or medical condi- analyzed health data of two million children born
tions that prohibit breastfeeding (6). between 1977 and 2012. Children born by cesarean deliv-
ery had a significantly increased risk of asthma, systemic
Vaginal Seeding connective tissue disorders, juvenile arthritis, inflamma-
Vaginal seeding refers to the practice of inoculating tory bowel disease, immune deficiencies, and leukemia.
a cotton gauze or cotton swab with vaginal fluids to Because this review did not identify differences in risk
transfer the vaginal flora to the mouth, nose, or skin of a between children born by cesarean delivery with or
newborn infant. The procedure is most often performed without labor or by delivery with or without rupture of
in conjunction with cesarean delivery. Cesarean delivery membranes, the specific effect of the lack of fetal expo-
performed before the onset of labor or before the rup- sure to the maternal vaginal microbiota is unknown.
ture of membranes prevents the fetus from coming into This association between cesarean delivery and increased
contact with vaginal fluid and bacteria. The intended risk of several chronic immune diseases suggests a shared
purpose of vaginal seeding is to transfer maternal vaginal environmental risk factor in early life. Further research is
bacteria to the newborn. As the increase in the frequency needed to clearly identify and address this risk factor (8).
of asthma, atopic disease, and immune disorders mir- Prospective studies have demonstrated that an infant
rors the increase in rate of cesarean delivery, the theory delivered vaginally acquires microbiota resembling his or
of vaginal seeding is to allow for proper colonization of her mother’s vaginal microbiota and that an infant born
the fetal gut and, therefore, reduce the subsequent risk by cesarean delivery initially develops bacterial coloniza-
of asthma, atopic disease, and immune disorders. The tion resembling skin colonization from the mother or
lay press in the United States and abroad has shown an from the operating room microbiota (9, 10). A system-
interest in the concept of vaginal seeding. As a result, it atic review of associations between mode of delivery and
has become increasingly common for patients to discuss the diversity and colonization pattern of gut microbiota
the possible benefits of performing vaginal seeding with during the first year of infant life found that the diversity
cesarean delivery with their obstetrician–gynecologists or and colonization pattern were significantly associated
other obstetric care providers. This Committee Opinion with the mode of delivery from birth to 3 months of life,
has been prepared in response to this public interest. but that the difference disappeared after 6 months (11).
A small study of 60 randomly selected 7-year-old
Association Between Mode of children, 31 delivered by cesarean and 29 delivered vagi-
Delivery and Allergic Disorders nally, assessed microbiota composition by determining
The incidence of cesarean delivery has increased dra- fecal microbiota profiles using culture-independent fluo-
matically in the United States and in the rest of the indus- rescent in situ hybridization and compared the respec-
trialized world. Concurrently, the incidence of allergic tive effects of delivery mode on gut microbiota (12).
and autoimmune diseases has increased. It has long Significantly higher numbers of clostridia (generally
been hypothesized that neonatal exposure to the vaginal considered a harmful species) were found in children
flora during vaginal birth reduces the risk of developing delivered vaginally compared with children born by
allergic disorders. This relationship has been suggested cesarean delivery. No differences were observed in other
from retrospective studies yet it remains unproved. A fecal bacteria, including Bifidobacterium, which gener-
retrospective cohort study from 2005 reported on 8,953 ally is considered helpful for health promotion, or total
children in Oregon diagnosed with allergic rhinocon- numbers of bacteria. Children with asthma diagnosed
junctivitis, asthma, atopic dermatitis, or food allergies. by a physician had lower numbers of clostridia in their
The risk of an allergic rhinoconjunctivitis diagnosis was fecal specimens, whereas healthy children had higher

VOL. 130, NO. 5, NOVEMBER 2017 Committee Opinion Vaginal Seeding e275
clostridial numbers. Although the authors conclude that Microbiota Restoration in the
abnormal development of intestinal microbiota after Newborn Infant Born by Cesarean
cesarean delivery may continue beyond infancy, the rela- Delivery
tionship between vaginal birth, clostridial colonization,
and asthma remains unclear. The microbiota of all infants born by cesarean delivery
cannot be considered uniformly because some infants are
Childhood Asthma born by cesarean delivery after onset of labor or the rup-
Asthma is the most prevalent pediatric chronic disease ture of membrane whereas other infants are born before
and it affects more than 300 million people (13). One the onset of labor or before the rupture of membranes.
child in 10 in the Western world has asthma. A multi- Therefore, exposure to maternal vaginal bacteria will vary
tude of risk factors for the development of asthma have among all infants born by cesarean delivery. A pilot study
been identified. Childhood exposure to environmental of 18 newborns (7 born vaginally and 11 by cesarean
allergens, air pollution, and particulate matter and delivery) and their mothers was conducted in an attempt
viral respiratory tract infections are all associated with to partially restore the microbiota of infants born by
an increased risk of developing childhood asthma (14). cesarean delivery using vaginal microbial transfer (vagi-
The risk of developing asthma has also been associ- nal seeding) (18). Four of the 11 infants born by cesarean
ated with the type of bacteria contributing to the gut delivery were exposed to vaginal fluids from gauze inocu-
microbiota during the first 100 days of life. Infants lated in the vaginas of their respective mothers who were
monitored in the Canadian Healthy Infant Longitudinal negative for group B streptococci, had no signs of vagi-
Development study who were found to be at risk of devel- nosis, and had a vaginal pH less than 4.5, during the hour
oping asthma had relative decreases in the abundances of preceding cesarean delivery. Within 2 minutes of birth,
the genus Lachnospira (associated with atopic wheezing the infants were wiped with the gauze along the mouth,
in children) and increases in the species Clostridium neo- face, and skin. Serial cultures from the anus, mouth,
natale (associated with neonatal necrotizing enterocolitis) and skin of the infants and women were taken during
compared with matched controls (15). The authors con- the first month of life. Cultures were obtained from all
clude that the opposing shifts in the abundance of these 18 infants and women. Bacterial source tracking of the
two species in the first 3 months of life suggest they play infant microbiome revealed that the microbiome of the
a role in protecting against (Lachnospira) or promoting four infants born by cesarean delivery and wiped with the
(C neonatale) the development of asthmatic phenotypes inoculated gauze resembled that of infants delivered vagi-
seen in preschool-aged children. Infants born by cesarean nally, particularly so during the first week of life. Effects
delivery are known to have greater colonization with upon the microbiome beyond the first 30 days of life
Clostridium within the first 3 weeks of life though not at and the effects upon long-term health of the four infants
180 days (11). are not known. The results of this study have generated
Recently, factors have been identified that may interest in the scientific community and even larger inter-
reduce the risk of developing asthma, including envi- est in the international lay population and social media.
ronmental exposures after birth and increased intake of However, as only four infants underwent vaginal seeding,
n-3 fatty acids. A study of Amish and Hutterite children, this study has neither the size nor the power to produce
which included a mouse model, examined exposure to appropriate conclusions or recommendations or to con-
Amish house dust (which has significantly higher endo- firm the safety of vaginal seeding. Additional larger scale
toxin levels) and indicated that the Amish environment studies are necessary to further explore potential benefits
provides protection against asthma by engaging and shap- and risks of this practice.
ing the innate immune response (16). In a separate ran-
domized trial, 736 pregnant women were assigned to Clinical Considerations
receive daily supplemental fish oil (n-3 long-chain poly- It is critical to note that the current state of cumulative
unsaturated fatty acids) or placebo (olive oil) beginning investigative data into the potential benefit and harm
at 24 weeks of gestation through the first postpartum of vaginal seeding at this time consists of a single pilot
week to assess the benefit of fish oil supplementation on study in which only four infants underwent seeding, with
wheezing disorders in offspring. The cohort of 695 chil- no long-term follow up. It is also critical to note that the
dren from these pregnancies was observed for 5 years. The pilot study involved only women who were not carriers
risk of persistent wheeze or asthma was reduced by one of group B streptococci, had no signs of vaginosis, and
third in the first 5 years of life among the children born had a vaginal pH less than 4.5. Because 20% of pregnant
to women who received fish oil supplementation (17). women at term are carriers of group B streptococci, the
In light of the broad evidence of environmental, risk of performing vaginal seeding in the general popu-
dietary, and genetic factors that affect the risk of develop- lation is unknown. Of additional concern is the risk of
ing asthma, the contribution of variations in early micro- undiagnosed C trachomatis, N gonorrhea, human papil-
biota of children associated with delivery route remains loma virus, group A streptococci, and herpes simplex
unknown. virus infections, among others, at the time of delivery

e276 Committee Opinion Vaginal Seeding OBSTETRICS & GYNECOLOGY

that could result in neonatal infection that may otherwise 4. Bion V, Lockett GA, Soto-Ramirez N, Zhang H, Venter
have been potentially avoided by cesarean delivery with- C, Karmaus W, et al. Evaluating the efficacy of breastfeed-
out seeding. ing guidelines on long-term outcomes for allergic disease.
Should a patient insist on performing the proce- Allergy 2016;71:661–70. ^
dure herself, a thorough discussion with the patient 5. den Dekker HT, Sonnenschein-van der Voort AM, Jaddoe
should be held acknowledging the potential risk of VW, Reiss IK, de Jongste JC, Duijts L. Breastfeeding and
asthma outcomes at the age of 6 years: The Generation R
transferring pathogenic organisms from the woman to
Study. Pediatr Allergy Immunol 2016;27:486–92. ^
the neonate. Risk stratification is reasonable for such
women in the form of testing for infectious diseases and 6. Optimizing support for breastfeeding as part of obstetric
practice. Committee Opinion No. 658. American College
potentially pathogenic bacteria. Serum testing for herpes of Obstetricians and Gynecologists. Obstet Gynecol 2016;
simplex virus and cultures for group B streptococci, 127:e86–92. ^
C trachomatis, and N gonorrhea should be encour- 7. Renz-Polster H, David MR, Buist AS, Vollmer WM,
aged. It is further recommended that the obstetrician– O’Connor EA, Frazier EA, et al. Caesarean section delivery
gynecologist or other obstetric care provider document and the risk of allergic disorders in childhood. Clin Exp
the discussion. Because of the theoretical risk of neonatal Allergy 2005;35:1466–72. ^
infection, the pediatrician or family physician caring for 8. Sevelsted A, Stokholm J, Bonnelykke K, Bisgaard H.
the infant should be made aware that the procedure was Cesarean section and chronic immune disorders. Pediatrics
performed. The American College of Obstetricians and 2015;135:e92–8. ^
Gynecologists only supports the performance of vaginal 9. Dominguez-Bello MG, Costello EK, Contreras M, Magris
seeding in the context of an institutional review board- M, Hidalgo G, Fierer N, et al. Delivery mode shapes the
approved research protocol. acquisition and structure of the initial microbiota across
multiple body habitats in newborns. Proc Natl Acad Sci U
Conclusion S A 2010;107:11971–5. ^
It has been hypothesized that the increasing prevalence 10. Shin H, Pei Z, Martinez KA 2nd, Rivera-Vinas JI, Mendez
of childhood asthma, atopic disease, and other immune K, Cavallin H, et al. The first microbial environment of
infants born by C-section: the operating room microbes
disorders may be the result of the increasing incidence of [published erratum appears in Microbiome 2016;4:4].
cesarean delivery, which may prevent natural coloniza- Microbiome 2015;3:59. ^
tion of the neonatal gut with maternal vaginal flora. It is 11. Rutayisire E, Huang K, Liu Y, Tao F. The mode of delivery
also possible that antenatal and intrapartum antibiotics as affects the diversity and colonization pattern of the gut
well as formula feeding may contribute to this dysbiosis. microbiota during the first year of infants’ life: a systematic
This hypothesis is supported solely by small retrospective review. BMC Gastroenterol 2016;16:86,016-0498-0. ^
studies. If the hypothesis is true, the best process to com- 12. Salminen S, Gibson GR, McCartney AL, Isolauri E.
pensate for this dysbiosis of the neonatal gut is unknown. Influence of mode of delivery on gut microbiota composi-
There is only one clinical trial (19) currently underway tion in seven year old children. Gut 2004;53:1388–9. ^
to investigate vaginal seeding, but the main outcome 13. Arrieta MC, Stiemsma LT, Dimitriu PA, Thorson L, Russell
measure is neonatal microbiota, not clinical outcomes. S, Yurist-Doutsch S, et al. Early infancy microbial and
At this time, the American College of Obstetricians and metabolic alterations affect risk of childhood asthma. Sci
Gynecologists does not recommend or encourage vaginal Transl Med 2015;7:307ra152. ^
seeding outside of the context of an institutional review 14. Gaffin JM, Kanchongkittiphon W, Phipatanakul W.
board-approved research protocol, and it is recom- Perinatal and early childhood environmental factors
mended that vaginal seeding otherwise not be performed influencing allergic asthma immunopathogenesis. Int
until adequate data regarding the safety and benefit of Immunopharmacol 2014;22:21–30. ^
the process become available. The paucity of data on this 15. Stiemsma LT, Arrieta MC, Dimitriu PA, Cheng J, Thorson
subject supports the need for additional research on the L, Lefebvre DL, et al. Shifts in Lachnospira and Clostridium
safety and benefit of vaginal seeding. sp. in the 3-month stool microbiome are associated with
preschool age asthma. Clin Sci (Lond) 2016;130:2199–207.
^
References
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 microbiota of cesarean-born infants via vaginal microbial Copyright November 2017 by the American College of Obstetricians
transfer. Nat Med 2016;22:250–3. ^ and Gynecologists. All rights reserved. No part of this publication may
19. New York University School of Medicine. Potential be reproduced, stored in a retrieval system, posted on the Internet,
or transmitted, in any form or by any means, electronic, mechanical,
Restoration of the Infant Microbiome (PRIME). In: photocopying, recording, or otherwise, without prior written permis-
ClinicalTrials.gov. Bethesda (MD): National Library of sion from the publisher.
Medicine; 2015. ^ Requests for authorization to make photocopies should be directed
to Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA
01923, (978) 750-8400.
The American College of Obstetricians and Gynecologists
409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920
Vaginal seeding. Committee Opinion No. 725. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2017:130:e274–8.

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is
voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care.
It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in
the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or
advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publica-
tions may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center.
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e278 Committee Opinion Vaginal Seeding OBSTETRICS & GYNECOLOGY