Perineal status code N[N]

Guide for use:

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
• vagina
• 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
• 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.

Origin:
National Centre for Classification in Health (NCCH) 2010. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) – Seventh Edition - Tabular list of diseases and Alphabetic index of diseases. Sydney: NCCH, Faculty of Health Sciences, The University of Sydney.

Comments:

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. Instead, the category has been added to the value domain as a new code rather than modifying the order of the existing permissible values. This approach is consistent with established practice in classifications, wherein a new value domain identifier (or code number) is assigned to any new value meaning that occurs, rather than assigning this new value domain meaning to an existing value domain identifier.