Plate-Sized Device Found Inside Woman’s Abdomen 18 Months After Cesarean Delivery | cnn

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A dinner plate-sized surgical tool was found inside a woman’s abdomen 18 months after her baby was born Caesarean sectionaccording to a report by the New Zealand Health and Disability Commissioner.

An Alexis retractor, or AWR, which can measure 17 centimeters (6 inches) in diameter, was left inside the mother’s body after the birth of her baby at Auckland City Hospital in 2020.

The AWR is a retractable cylindrical device with a translucent film used to remove the edges of a wound during surgery.

The woman suffered months of chronic pain and underwent several checkups to find out what was wrong, including X-rays that showed no sign of the device. The pain became so severe that she visited the hospital emergency department and the device was discovered on an abdominal CT scan and immediately removed in 2021.

New Zealand Health and Disability Commissioner Morag McDowell found that Te Whatu Ora Auckland (the Auckland District Health Board) was in breach of the patients’ code of rights, in a report published on Monday.

The board of health initially claimed that a nurse, in her 20s, who was attending to the woman during the caesarean section had failed to demonstrate reasonable skills or care towards the patient.

“As established in my report, the care was significantly below the appropriate standard in this case and resulted in a prolonged period of distress for the woman,” McDowell said. “Systems should have been in place to prevent this from happening.”

The report explained that the woman was scheduled for a C-section due to concerns about placenta previa, a problem during pregnancy when the placenta fully or partially covers the opening of the uterus.

During the operation in 2020, the count of all surgical instruments used in the procedure did not include the AWR, according to the commission’s report. This was possibly due “to the fact that the Alexis retractor does not go all the way into the wound as half of the retractor needs to remain outside the patient and therefore would not be at risk of being retained,” a nurse told the commission. .

McDowell recommended that the Auckland District Health Board make a written apology to the woman and review its policies including AWRs as part of the surgical count.

The case has also been referred to the director of proceedings, an official who will determine whether further action should be taken.

Dr. Mike Shepherd, Te Whatu Ora Health New Zealand Group COO of Te Toka Tumai Auckland, apologized for the error in a statement.

“On behalf of our Women’s Health service at Te Toka Tumai Auckland and Te Whatu Ora, I would like to express how sorry we are for what happened to the patient and acknowledge the impact this will have had on her and her whānau (family). cluster).”

“We would like to reassure the public that incidents like these are extremely rare and we remain confident in the quality of our maternity and surgical care.”