Female (mother)—postpartum perineal status, code N[N]

• Health, Superseded 12/12/2018

Perinatal statistics

CODE 2   1st degree laceration/vaginal graze

Graze, laceration, rupture or tear of the perineal skin during delivery that may be considered to be slight or that involves one or more of the following structures:

• fourchette
• labia
• periurethral tissue (excluding involvement of urethra)
• vagina, low
• vulva.

CODE 3   2nd degree laceration

Perineal laceration, rupture or tear as in Code 2 occurring during delivery, also involving:

• pelvic floor
• perineal muscles
• vaginal muscles.

Excludes laceration involving the anal sphincter.

CODE 4   3rd degree laceration

Perineal laceration, rupture or tear as in Code 3 occurring during delivery, also involving:

• anal sphincter (excluding involvement of anal or rectal mucosa)
• rectovaginal septum
• sphincter not otherwise specified (NOS).

Excludes laceration involving the anal or rectal mucosa.

CODE 7   4th degree laceration

Perineal laceration, rupture or tear as in Code 4 occurring during delivery, also involving:

• anal mucosa
• rectal mucosa.

CODE 88   Other perineal laceration, rupture or tear

May include haematoma or unspecified perineal tear.

If a laceration occurred during delivery and an episiotomy was performed, both the degree of laceration and the episiotomy should be recorded. If an episiotomy is performed, the perineum cannot be intact.

Code 6 has been omitted as it is no longer in use. For information about its meaning in previous data elements, see superseded versions.

While 4th degree laceration is more severe than an episiotomy, this category has not been placed in order of clinical significance within the value domain.

Australian Institute of Health and Welfare

Australian Consortium for Classification Development (ACCD) 2017. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth edn. Tabular list of diseases and Alphabetic index of diseases. Sydney: ACCD, University of Sydney.

Multiple entries of permissible values are allowed.

Perineal laceration (tear) may cause significant maternal morbidity in the postnatal period. Episiotomy is an indicator of management during labour and, to some extent, of obstetric intervention.