Practice Safety Alerts

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

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3679 (Published 19 July 2010) Cite this as: BMJ 2010;341:c3679
  1. Tara Lamont, head of patient safety1,
  2. Anita Dougall, maternity lead1,
  3. Sara Johnson, head of patient safety1,
  4. Dinah Mathew, research and evaluation lead1,
  5. John Scarpello, deputy medical director1,
  6. Edward Morris, consultant obstetrician2
  1. 1National Patient Safety Agency, London
  2. 2Norfolk and Norwich University Hospital, Norfolk
  1. Correspondence to: T Lamont tara.lamont{at}npsa.nhs.uk

    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 …

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