Female—postpartum perineal status, code N[N]

Identifying and definitional attributes

• Health, Superseded 03/12/2020

Perinatal

Value domain attributes

Representational attributes

Collection and usage attributes

CODE 1   Intact

Should not be recorded in conjunction with any other code.

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
• skin
• vulva.

Should not be recorded in conjunction with any other code except for Code 5 (Episiotomy).

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. Should not be recorded in conjunction with any other code except for Code 5 (Episiotomy).

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. Should not be recorded in conjunction with any other code except for Code 5 (Episiotomy).

CODE 7   4th degree laceration

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

• anal mucosa
• rectal mucosa.

Should not be recorded in conjunction with any other code except for Code 5 (Episiotomy).

CODE 88   Other perineal laceration, rupture or tear

May include haematoma or unspecified perineal tear. Should not be recorded in conjunction with any other code except for Code 5 (Episiotomy).

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.

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.

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 For information about its meaning in previous data elements, see superseded versions.

Source and reference attributes

Australian Institute of Health and Welfare

ACCD (Australian Consortium for Classification Development) 2019. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM), 11th edn. Tabular list and Alphabetic index. Darlinghurst, NSW: Independent Hospital Pricing Authority.

Data element attributes

Collection and usage attributes

More than one permissible value may be recorded.

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.

Relational attributes