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Managing Sponges in Labor and Delivery

Retained vaginal sponges after a spontaneous vaginal birth or vaginal packing left after an operation are reportable Retained Surgical Item events. For the purposes of this report, a sponge is considered retained if it was discovered after the immediate recovery period (one to two hours after delivery).Vaginal packing is considered retained if a patient still has a pack in her vagina 24 hours after delivery or after discharge from the hospital.Minnesota has been proactive in addressing this problem and this definition is consistent with their guidelines and those used in general obstetrical practice. (1) Retained vaginal sponges may not be frequently reported because they are removed in physician’s offices but when reported the vagina is the most common site for a retained sponge after the chest and abdomen. (2,3,4)

Poor communication between birth attendants (physicians, nurse midwives) and other labor and delivery staff and problems with obstetrical practices of sponge management can result in the failure to remove surgical sponges after a vaginal birth. Although the practice of surgical counts has long been standard in operating rooms, a lack of familiarity with the practice for vaginal births is one reason why vaginal sponge retention is a problem. Another reason is under-appreciation of patient harm that can result from retention.

Sponges left in the vagina are usually the 4×4 cotton gauze X-ray–detectable sponges (“Ray-TecR”). These are small in comparison to a post-gravid vagina and contrary to obstetrician’s perceptions that they will be able to see or “find” them, indeed, they are missed. Women usually present days to weeks after delivery with a vaginal discharge. Sometimes they have a fever and abdominal pain and signs of endometritis. They go to doctor’s offices and to the emergency room. Sometimes they remove or report the finding of a soiled, fetid piece of “tissue” or gauze that falls out in the toilet or they perceive something is inside of them. They are often put on antibiotics. There have been reported cases of toxic shock syndrome associated with a missed retained vaginal sponge. (5) Hospitals have to report these cases per California statue if they are discovered or patients can report them.

Birthing and L&D (labor and delivery) areas in addition to obstetrical ORs should have in place a standardized practice for the management of surgical sponges. (6) Which practice is chosen is dependent on the local environment and facility resources. It is probably a good idea that the practice which is in place in the OR is also employed in the L&D areas. L&D personnel often do not have familiarity with sponge management practices like OR nurses do so help from their OR colleagues can make their learning curve shorter. Some additional safety actions are to use 4″×18″ gauze sponges instead of the 4×4s because they are longer, have a blue marker which can hang outside of the perineum during a repair and some think they are easier to find so will be easier to keep track of. Vaginal packing should not be in the delivery packs. If vaginal packing is needed a pack with a radiopaque marker should be opened.

Vaginal packing is considered a dressing so a process has to be in place outside of the OR or birthing room which will ensure that the dressing pack is removed before the patient goes home. This three-step practice is recommended (7) —

  1. During the nurse handoff to postdelivery personnel there is formal notation made that there is a pack in the patient
  2. The obstetrician writes an order that there is a pack placed and the timing and plan for pack removal
  3. The patient is informed there is a pack in her and it must come out before she goes home.

When surgical sponges are used they should be accounted for at the end of the procedure. Obstetricians and perinatal personnel should adopt safe practices to ensure that patients and new mothers leave the OR or procedure area with “NoThing Left Behind”.

References

1. Institute for Clinical Systems Improvement. (2007). Prevention of Unintentionally Retained Foreign Objects During Vaginal Deliveries.

2. Wan, W., Le, T., Riskin, L., & Macario, A. (2009). Improving safety in the operating room: a systematic literature review of retained surgical sponges. Current Opinion in Anaesthesiology. 22, 207-14.

3. California Department of Public Health. (2010). Fiscal Year 2010-2011 Adverse Events Addendum.

4. Institute for Clinical Systems Improvement. (2009). Prevention of Unintentionally Retained Foreign Objects During Vaginal Deliveries.

5. McGregor, J.A., Soper, D.E., Lovell, G., & Todd J.K. (1989). Maternal deaths associated with Clostridium sordelli infection. American Journal of Obstetrics and Gynecology. 4, 987-95.

6. Chagolla B. A., Gibbs V.C., Keats J.P., & Pelletreau B. (2011). A Systemwide Initiative to Prevent Retained Vaginal Sponges. Accepted for publication, The American Journal of Maternal Child Nursing.

7. Gibbs V.C. — NoThing Left Behind®: A National Surgical Patient Safety Project to Prevent Retained Surgical Items

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