Emergency cesarean deliveries often are performed without an initial instrument count. Following closure, and prior to transporting the patient to the recovery room, an abdominal radiograph is ordered to ensure no instruments or sponges are present. Over a 9-month period, an unusual artifact occasionally would appear on closing radiographic images, causing considerable alarm (see Figure 1). Radiologists described the artifact as "a linear radi-opaque density approximately 3 cm in length of unknown etiology." When the artifact would appear on a closing radiograph, additional radiographic images would be ordered to determine the location of the object and whether it was inside the patient's body. These additional images, acquired after the surgical drapes had been removed, no longer demonstrated the foreign object (see Figure 2). The imaging and surgical departments worked together to identify the source of the artifact. Confounding factors included the infrequent appearance of the density, the inconsistent location on each image, and the use of more than one operating room. Numerous efforts were undertaken to determine the cause of the artifact. These efforts included radiographing surgical table pads and using different imaging cassettes. Despite these efforts, the artifact could not be reproduced.
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