Reducing the risk of retained swabs after vaginal birth: summary of a safety report from the National Patient Safety Agency

Why read this summary?

Swabs are used by obstetricians and midwives during vaginal birth and perineal suturing to clean and absorb blood. They can be difficult to identify once soaked in blood and are occasionally left inside the vagina by mistake. This error can cause fever, infection, pain, secondary postpartum haemorrhage, and psychological harm.

Between April 2007 and March 2009, 99 incidents of swabs left in the vagina after birth were reported by healthcare staff in England and Wales. Thirty four of these reports described signs of infection. Litigation claims for the same period showed a further 18 relevant cases.

A typical incident report reads: “Day 8 post NB [Neville Barnes] forceps delivery felt something coming out of vagina. On examination, large swab removed from vagina; swabs taken. Temperature 38°c. Commenced intravenous erythromycin (allergic to penicillin) and metronidazole.”

In perioperative settings, there are established processes for recording and counting swabs. Some of these routine checks could be adapted for use in maternity services, while recognising the range of birth environments.

This summary is based on a new safety report (known as a “rapid response report” or “RRR”) from the National Patient Safety Agency (NPSA) on reducing the risk of retained swabs after vaginal birth and perineal suturing, issued in May 2010. The RRR recommends key actions for staff (NPSA/2010/RRR12; www.nrls.nps.nhs.uk).

What can we do?

In the RRR, the NPSA asked all maternity services to have written procedures in place for swab counts at all births and perineal repairs, and to audit this practice. We recommended a standardised process adapted from general guidance on intrapartum care,1 existing perioperative practice,2 and guidelines from the United States.3

For individual clinicians:

• Always count swabs before and after the procedure. Where possible, do this audibly with a colleague (double counting). Include tampons in the count, which may be used for retraction of tissues during repair of perioperative vaginal tears.

• Record the count (before and after) in the woman’s maternity notes or in the electronic maternity record.

• Where appropriate, record swab counts on a wipe clean surface kept in labour rooms, such as a whiteboard.

• Separate swabs during counting and use a dedicated container for all used swabs. Do not remove used swabs from the area until all counts are reconciled.

• If a woman is transferred to surgery following an emergency during or immediately after a vaginal delivery, document any count in the woman’s record and communicate this to the surgical team.

• Use swabs that are detectable on radiography and have safety features, such as tails or tags. Large swabs are more appropriate for this use.

• If a retained swab is suspected, examine the woman, with vaginal bacterial testing and a pelvic radiograph as needed. If the woman is clinically unwell, arrange an obstetric review and start appropriate therapy.

What else do we need to know?

There is little evidence in this area, and most of the evidence relates to swabs and instruments retained after general surgical procedures rather than vaginal births. We do not know how frequently swabs are left in the vagina after birth because incidents are likely to be under-reported to the NPSA. We also do not have robust evidence on the effectiveness of interventions to reduce harm. However, a retrospective study in the US identified several cases of retained swabs after the closure of episiotomy or vaginal tear, and in all cases a count had not been done.4 Counting of instruments and swabs is standard perioperative practice and despite some evidence of unreliability of counting,5 it is likely that such simple checks would have prevented most of the cases identified in the US study and reported by staff to the NPSA, whatever the setting.

How will we know when practice has become safer?

Organisations have been given until November 2010 to implement the actions in this RRR and are required to report compliance at that point. The NPSA will continue to monitor incidents reported by staff. This issue would be a good topic for local audit to measure compliance with what should be a routine basic safety process.