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.
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
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) —
During the nurse handoff to postdelivery personnel there is
formal notation made that there is a pack in the patient
The obstetrician writes an order that there is a pack placed
and the timing and plan for pack removal
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
1. Institute for Clinical Systems Improvement. (2007). Prevention
of Unintentionally Retained Foreign Objects During Vaginal
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.
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,
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