Detection of retained vaginal swabs and tampons following childbirth

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Women can be left in severe pain and at risk of infection if 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 several procedures in delivery suites and surgical theatres on maternity wards. They are intended to be removed once a procedure is complete.

Retained vaginal swabs are classed as a ‘never event’. A never event is a serious incident that is entirely preventable. Data compiled by NHS England/Improvement shows that accidental retention of vaginal swabs is the most common never event in the ‘retained foreign objects’ category.

This report sets out the case of Christine, a 30-year-old woman who had a surgical tampon inserted after the birth of her first child. It was left in and not discovered until five days after leaving hospital. Whilst being in immense pain throughout, Christine saw the community midwife and GP twice before going back to hospital where the tampon was found.

Our investigation looked at the detection and design of vaginal swabs and tampons.

The investigation found that:

• Whilst current methods like ‘count practices’ (using whiteboards to count and track the whereabouts of equipment in theatres) have had some success, they are not a robust barrier in reducing risk.
• The lack of visibility of swabs and tampons also contributes to the likelihood that they will be accidentally left in. NHS England/Improvement is exploring potential solutions including a redesign to swabs and tampons and will publish its full evaluation in due course.