Female—postpartum perineal status, code N[N]

Identifying and definitional attributes

Metadata item type:Data Element
Short name:Postpartum perineal status
METeOR identifier:732864
Registration status:Health, Standard 03/12/2020
Definition:

The state of a female's perineum following birth, as represented by a code.

Context:

Perinatal

Data Element Concept:Female—postpartum perineal status

Value domain attributes

Representational attributes

Representation class:Code
Data type:Number
Format:N[N]
Maximum character length:2
Permissible values:
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:
99Not stated/inadequately described

Collection and usage attributes

Guide for use:

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:

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:

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:

Australian Institute of Health and Welfare

Origin:

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

Guide for use:

More than one permissible value may be recorded.

Comments:

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

Related metadata references:

Has been superseded by Female—postpartum perineal status, code N[N] Health, Candidate 07/10/2021

Supersedes Female—postpartum perineal status, code N[N] Health, Superseded 03/12/2020

Implementation in Data Set Specifications:

Perinatal NMDS 2021–22 Health, Standard 03/12/2020

DSS specific attributes +