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Perineal status code N[N]

Identifying and definitional attributes

Metadata item type:Help on this termValue Domain
METeOR identifier:Help on this term732861
Registration status:Help on this termHealth, Standard 03/12/2020
Definition:Help on this term

A code set representing the state of the perineum.

Representational attributes

Representation class:Help on this termCode
Data type:Help on this termNumber
Format:Help on this termN[N]
Maximum character length:Help on this term2
Permissible values:Help on this term
ValueMeaning
1Intact
21st degree laceration/vaginal graze
32nd degree laceration
43rd degree laceration
5Episiotomy
74th degree laceration
88Other perineal laceration, rupture or tear
Supplementary values:Help on this term
99Not stated/inadequately described

Collection and usage attributes

Guide for use:Help on this term

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).

Collection methods:Help on this term

Jurisdictions that record perinatal data using the ICD-10-AM should apply the following codes in relation to degree of laceration:

‘Code 2 1st degree laceration/vaginal graze' is equivalent to O70.0 in the ICD-10-AM.

'Code 3 2nd degree laceration ' is equivalent to O70.1 in the ICD-10-AM.

'Code 4 3rd degree laceration' is equivalent to O70.2 in the ICD-10-AM.

'Code 7 4th degree laceration' is equivalent to O70.3 in the ICD-10-AM.

'Code 88 Other perineal laceration, rupture or tear' is equivalent to O70.9 in the ICD-10-AM.

Comments:Help on this term

Where multiple perinatal lacerations, ruptures or tears of different degrees are documented, assign the code for the highest (most severe) degree only.

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 (Combined laceration and episiotomy) 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

Submitting organisation:Help on this term

Australian Institute of Health and Welfare

Origin:Help on this term

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.

Relational attributes

Related metadata references:Help on this term

Has been superseded by Perineal status code N[N] Health, Standardisation pending 22/10/2021

Supersedes Perineal status code N[N] Health, Superseded 03/12/2020

Data elements implementing this value domain:Help on this term

Femaleā€”postpartum perineal status, code N[N] Health, Standard 03/12/2020

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