[Skip to content]

NHS
Loading
.

Reducing the risk of retained swabs after vaginal birth and perineal suturing

Reference number
1229
Central Alert System (CAS) reference
NPSA/2010/RRR012
Issue date26 May 2010
Action date (if applicable) (date field)26 November 2010
DH Gateway reference
14333
TypeAlert

Swabs are used in maternity care for cleansing and to absorb blood and other fluids. They are usually pre-packed in delivery and suture packs. Swabs can be difficult to identify once soaked in blood and are sometimes mistakenly left inside the vagina. Retained swabs following a vaginal birth are a source of maternal morbidity, including pyrexia, infection, pain, secondary post-partum haemorrhage and psychological problems.

 

Maternity services in England and Wales promote normal birth and it is recognised that there are a number of different birth environments, including the home. However, wherever swabs are used they should be accounted for every time.

 

All NHS organisations providing maternity services should:

 

1. have written procedures in place for swab counts at all births (including perineal suturing);


2. audit swab count practices in their maternity services;


3. provide education and training about the counting procedure for all midwifery, obstetric and support staff;


4. ensure that lead professionals (midwives and obstetricians) are aware of their responsibility for documenting the completed swab count in the woman’s health record;


5. in conjunction with their supplies department, risk assess sterile delivery and perineal suture packs and consider using  x-ray detectable swabs;


6. ensure staff report incidents of swabs retained after vaginal births and perineal suturing as patient safety incidents;


7. cascade the clinical briefing sheet to relevant staff to raise awareness of the risks of swabs being unintentionally retained following vaginal births and perineal suturing.

 

Actions should be led by the director of nursing supported by the head of midwifery.

Reducing the risk of retained swabs after vaginal birth and perineal suturing
Reducing the risk of retained swabs after vaginal birth and perineal suturing - 51 KB NRLS | Retained swabs after vaginal birth | RRR | 2010-05-26 | v1
Reducing the risk of retained swabs after vaginal birth and perineal suturing supporting information
Reducing the risk of retained swabs after vaginal birth and perineal suturing supporting information - 79 KB 1229 A | Retained swabs after vaginal birth supporting information | RRR | 2010-05-26 | v1
Reducing the risk of retained swabs after vaginal birth and perineal suturing: briefing for maternit
Reducing the risk of retained swabs after vaginal birth and perineal suturing: briefing for maternit - 293 KB 1229 B | Retained vaginal swabs briefing for maternity services | RRR | 2010-05-26 | v1
Reducing the risk of retained swabs after vaginal birth and perineal suturing: briefing for healthca
Reducing the risk of retained swabs after vaginal birth and perineal suturing: briefing for healthca - 177 KB 1229 C | Retained vaginal swabs briefing for healthcare professionals | RRR | 2010-05-26 | v1