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Background . Policies for sponge count are not routine practice in most labor and delivery rooms. Ignored or hidden retained vaginal foreign bodies has potentially significant health care morbidity.  Case . This was a case of a retained vaginal sponge following an uncomplicated spontaneous vaginal delivery. Delivery room policy resulted in the discovery of the sponge on X-ray when an incorrect sponge count occurred and physical exam did not find the sponge.  Conclusion . This emphasizes the use of protocols to enhance patient safety and prevent medical error.

Policy for Prevention of a Retained Sponge after Vaginal Delivery