She Griped of Pain for Over a Year. Then, a Surprising Find

A New Zealand woman who gave birth by cesarean section in 2020 lived for 18 months with a surgical device "about the size of a dinner plate" concealed in her abdomen, according to a report released Monday. The unnamed woman in her 20s complained of chronic pain in the months after welcoming her child at Auckland City Hospital, but X-rays failed to show anything amiss, CNN reports. Finally, after a visit to the emergency room in 2021, health care workers ordered a CT scan, which showed an Alexis retractor, or AWR, apparently missed by the surgeon and 10 others involved in the woman's surgery, still inside her abdomen.

An AWR consists of two plastic rings joined by a plastic sleeve and is "used to draw back the edges of a wound during surgery," according to the report by Health and Disability Commissioner Morag McDowell. They're typically about 6 inches wide, per CNN, though the Guardian reports this one was "extra large." The report faulting Te Whatu Ora-Auckland, formerly the Auckland District Health Board, found the AWR was excluded from the count of surgical instruments used. As a nurse told the commission, that may be because "the Alexis retractor doesn't go into the wound completely, as half of the retractor needs to remain outside the patient, and so it would not be at risk of being retained."

It's unclear how the device was retained. "Usually, it would be removed after closing the uterine incision (and before the skin is sutured)," the report reads, per ABC News. "The care fell significantly below the appropriate standard in this case and resulted in a prolonged period of distress for the woman," McDowell wrote, per CNN, adding, "Systems should have been in place to prevent this from occurring." The report notes the case is "remarkably similar" to another instance in the same health authority, per the Guardian. It calls for the health board to pen an apology to the patient and to include AWRs in counts of surgical instruments. The case now heads to the commission's prosecutor, who will decide on further action. (More New Zealand stories.)