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National Patient Safety Agency

Frontline services urged to follow vaginal swab guidelines

26 MAY 2010


New guidance, produced by the National Patient Safety Agency (NPSA) and NHS organisations across England and Wales, has been issued aimed at reducing the risk of retained swabs after a vaginal birth.


The publication of this Rapid Response Report (RRR) follows 99 reported incidents, between 1 April 2007 and 31 March 2009 of swabs, which are used for cleansing and to absorb blood and other fluids, being left in the vagina after birth and perineal suturing.  Retained swabs can cause pyrexia*, infection, pain, post-partum haemorrhage* and psychological problems.  The degree of harm assigned to these incidents ranges from no harm to severe.


This guidance requires NHS organisations to have written procedures for swab counts at all births and to audit swab count practices in their maternity services.


The RRR also calls on NHS organisations to ensure:

• lead professionals are aware of their responsibility in documenting the completed swab count in the woman’s health records;
• education and training on the importance of counting swabs is provided for all midwifery, obstetric and support staff;
• that risk assessment of delivery and perineal suture packs used by midwives and obstetricians takes place.


Sara Johnson, Head of Patient Safety, Child Health and Maternity Care at the NPSA, said:  “Childbirth is, for most women, a normal physiological event which takes place in many different settings, including the woman's home.


“This RRR is not designed to introduce any unnecessary clinical interventions into the birth process but is to ensure the ongoing comfort and safety of the woman in the postnatal period.

“This guidance is necessary as the effects of infection and the psychological harm associated with these incidents can be significant and last beyond the immediate postnatal period.”


Janet Alderton, Midwife, Obstetrics and Gynaecology Clinical Governance Co-ordinator and Maternity Risk Management Coordinator at North Tees and Hartlepool NHS Foundation Trust, said:  "Ensuring that swabs are counted and checked when removed is an important part of patient safety.  This rapid response alert will focus on this important area within the maternity services.” 


Edward Morris, Clinical Director at Norfolk and Norwich University Hospitals NHS Foundation Trust, said: “If all maternity units are able to incorporate these steps into their delivery care pathways, robust processes for the counting of swabs will become normal practice, regardless of where the mother delivers her baby.  “The benefits of a straightforward standardised national system cannot be overstated.”


For more information on this RRR, please visit: NPSA Website



Notes to editors


*Definitions of terms


Pyrexia: A raised temperature associated with infection.


Post-partum haemorrhage: Excessive bleeding after childbirth. When associated with retained vaginal swabs, this can potentially take place some time after the birth.


1. Media enquiries to the NPSA Press Office:
Simon Morgan – 020 7927 9580 / simon.morgan@npsa.nhs.uk
Dominic Stevenson – 020 7927 9351 / dominic.stevenson@npsa.nhs.uk

Out of hours – 0788 411 5956


2. The National Patient Safety Agency (NPSA) is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. For more information visit: www.nrls.npsa.nhs.uk.