Posted by Sarah White, Associate
This ‘never event’ leaves women at risk of harm after childbirth, and is all too common
Sarah White takes a look at a recent report published by The Healthcare Safety Investigation Branch which highlights how women have been left in severe pain and at risk of infection when swabs and tampons used after childbirth are accidentally left in the vagina.
Vaginal swabs and surgical tampons (larger than tampons used by women during their menstrual cycle) are used to absorb bodily fluids in a number of procedures both in delivery suites and surgical theatres on maternity wards. They are intended to be removed once a procedure is complete.
If a swab is not removed a woman will begin to feel discomfort and pain. Other symptoms can also develop including an offensive smell, unusual discharge and recurrent infection. These symptoms can often be disregarded, especially the pain which is often attributed to the trauma of having a vaginal birth, but a number of serious complications can also occur including infection, post-partum haemorrhage and psychological damage.
Swabs and tampons being left inside the vagina are classed as ‘never events’ i.e. serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. Data compiled by NHS England/Improvement shows that accidental retention of vaginal swabs is the most common in the ‘retained foreign objects’ category. So how and why is this still happening?
In their report dated 18 December 2019 the HSIB highlight the case of Christine, a 30 year old woman who gave birth to her baby via assisted delivery with forceps. As part of the forceps delivery an episiotomy (a surgical incision of the perineum and the posterior vaginal wall) was performed.
After the birth of the baby and the placenta a surgical tampon was inserted into the vagina. This was to make the end of the cut more visible, which would in turn make the repair process easier. The Obstetrician started the repair, added two stitches and then asked the specialty trainee doctor to continue the repair. He then left the theatre. Once the perineal repair was complete Christine was transferred to a postnatal recovery room and was discharged home one day later.
In the four days that followed Christine experienced increasing perineal pain and made contact with various healthcare services including community midwives, general practitioners, the NHS 111 service and the hospital triage midwife a total of seven times.
On the evening of the fifth day after the birth Christine went back to the labour ward in significant pain. An examination by an Obstetrician revealed that there was a surgical tampon in her vagina. The tampon was removed and Christine was admitted to hospital where she was treated for pain and subsequent urinary retention. She was discharged home after eight days but suffered ongoing urological issues requiring further hospital visits and admissions. She has also required physiotherapy, psychosexual therapy and counselling.
How did this happen?
As a result of Christine’s case a clinician notified the HSIB of the safety risks involved with the retention of vaginal swabs and the potential for physical and psychological harm to women and an investigation was carried out.
Due to the fact that NHS England/Improvement are currently involved in work to find a solution to reduce the risk of retained vaginal swabs the HSIB decided that it was not appropriate for a full national investigation however they conducted a smaller scale investigation known as a ‘concise national investigation’.
The investigation focused on the use and detectability of swabs and tampons and explored the environmental and team factors that surrounded the incident.
The findings included:
- the speciality trainee doctor was not aware a tampon had or could be used during a perineal repair. The technique he had been trained in did not require a tampon or swab to be left inside the vagina during the procedure;
- the Trust’s process for swab/ tampon insertion and measures to reduce the risk of retention of swabs relies on staff performing many processes and procedures correctly. There were 17 different tasks in relation to the swab/tampon count and so numerous opportunities for error, especially considering that staff may be distracted by other tasks, fixated on the task they were performing or negatively affected by a lack of stimulation when carrying out a routine task and fatigue;
- the process for controlling instruments and swabs differed between vaginal obstetric theatre procedures and abdominal obstetric theatre procedures. During a forceps birth, as in Christine’s case, the scrub nurse would count the swabs at the beginning and at the end of the procedure but did not maintain oversight of where swabs and instruments were during the procedure. The HSIB stated that whilst current methods like ‘count practices’ (using whiteboards to count and track the whereabouts of equipment in theatres) have had some success, they aren’t a robust barrier in reducing risk;
- there were limitations in staff members’ perception of who owned the overall procedure and who was responsible for managing risks to patient safety;
- multiple handovers of the swab and instrument trolley were conducted;
- towards the end of the procedure there was a focus on the next task or activity resulting in practices such as leaving theatre before a procedure was complete. The handovers were therefore rushed or incomplete;
- there was a potential safety risk relating to how clinicians perceive and respond to reports of pain.
What is the outcome of this report?
The HSIB concluded that there needed to be a focus on changing the way people work rather than replacing the hazard itself.
Sandy Lewis, HSIB’s Maternity Investigation Programme Director, said:
“Although measures have been put in place to reduce the chance of swabs and tampons being left in, it continues to happen, leaving women in pain and distress when they may have already gone through a traumatic labour.
There are numerous physical effects; pain, bleeding and possible infection, but we can’t forget about the psychological impact as there was in Christine’s case – she had to seek private counselling and felt that what happened affected her ability to bond with her baby.
Retained vaginal swabs and tampons are a well-recognised issue and our investigation helps to shine a light on the risks. Through our investigation and subsequent report, we’ve provided an independent view. This will support the extensive national work being carried out in this area and help to improve outcomes for women across the country.”
NHS England/Improvement are exploring potential solutions including a redesign to swabs and tampons. The lack of visibility of swabs and tampons was found to contribute to the likelihood that they will be accidentally left in. NHS England/Improvement found that the absorbent material used in swabs, including the tail, turned red when in contact with bleeding and could look like human tissue, making them difficult to detect. A full evaluation report will be published in due course.
The HSIB stated that:
“It is recommended that NHS England/Improvement carries out its intention to commission and publish an independent evaluation of its alternative design for swabs and tampons. The evaluation should also consider other solutions or technologies and include usability, cost/benefit analysis and the impact on reducing harm.”
The HSIB observed that:
“It would be beneficial for trusts to review their planned handovers for all staff groups to have adequate time in their shift to conduct handover tasks and participate in team briefings”
It remains to be seen whether improvements will be made in this area to reduce or eliminate the number of retained vaginal swabs. Whilst there seems a lot of emphasis on looking at the design of the swabs there seems to be no real drive to change perceptions and attitudes of clinicians. The report highlighted issues regarding who took ‘ownership’ of the procedure and who was responsible for patient safety and also the way in which clinicians respond to reports of pain after the event. These are all important things that need to be worked on.
Leaving a swab in situ is a ‘never event’ by its definition is preventable. If you have been a victim of a never event or have any questions for our medical negligence specialists about how we aim to make the process of claiming compensation easier please contact us today.
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