A Guide to Obstetrical Coding - CIHI

1 ICD-10-CA | CCIA Guide to Obstetrical CodingUpdated February 2022 Production of this document is made possible by financial contributions from Health Canada and provincial and territorial governments. The views expressed herein do not necessarily represent the views of Health Canada or any provincial or territorial otherwise indicated, this product uses data provided by Canada s provinces and rights contents of this publication may be reproduced unaltered, in whole or in part and by any means, solely for non-commercial purposes, provided that the Canadian Institute for Health Information is properly and fully acknowledged as the copyright owner.

2 Any reproduction or use of this publication or its contents for any commercial purpose requires the prior written authorization of the Canadian Institute for Health Information. Reproduction or use that suggests endorsement by, or affiliation with, the Canadian Institute for Health Information is permission or information, please contact CIHI:Canadian Institute for Health Information495 Richmond Road, Suite 600 Ottawa, Ontario K2A 4H6 Phone: 613-241-7860 Fax: 2022 Canadian Institute for Health InformationHow to cite this document:Canadian Institute for Health Information.

3 A Guide to Obstetrical Coding . Ottawa, ON: CIHI; publication est aussi disponible en fran ais sous le titre Guide de codification des donn es en obst of contents About CIHI .. 6 Chapter 1: Introduction .. 7 Guide overview .. 7 Chapter 2: False and preterm labor .. 9 Chapter overview .. 9 Stages of labor .. 9 False labor .. 11 Preterm labor .. 12 Threatened preterm labor .. 13 Management of preterm labor .. 14 Exercises .. 15 Chapter summary .. 16 Case study .. 17 Chapter 3: Premature rupture of membranes.

4 18 Chapter overview .. 18 The clinical picture of premature rupture of membranes .. 18 Management of premature rupture of membranes2 .. 21 Classifying premature rupture of membranes .. 22 Classifying oligohydramnios and chorioamnionitis without PROM .. 24 Classifying delayed delivery after spontaneous or unspecified rupture of membrane with PROM .. 26 Exercises .. 26 Chapter summary .. 28 Case study .. 29 Chapter 4: Cervical ripening, induction and augmentation of labor ..30 Chapter overview.

5 30 Cervical ripening .. 30 Methods of cervical ripening .. 32 Induction of labor .. 32 Methods of inducing labor2 .. 34 Augmentation of labor .. 35 Failed induction of labor .. 36 A Guide to Obstetrical Coding 4 Exercises .. 37 Chapter summary .. 38 Case study .. 38 Chapter 5: Dystocia and failure to progress ..41 Chapter overview .. 41 Fetopelvic relationships .. 41 Mechanisms of normal labor1 .. 46 Dystocia, failure to progress and obstructed labor .. 49 Problems with the passenger Malposition and malpresentation, incomplete rotation of the fetal head.

6 51 Problems with the passage Cephalopelvic disproportion (CPD) .. 55 Other obstructed labor (O66) .. 56 Problems with the forces Uterine inertia and maternal fatigue .. 57 Exercises .. 58 Chapter summary .. 59 Case 60 Chapter 6: Operative vaginal delivery ..63 Chapter overview .. 63 Definitions related to operative vaginal delivery .. 63 Indications for operative vaginal delivery .. 66 Forceps delivery .. 67 Vacuum delivery .. 70 Failed forceps and vacuum .. 72 Application of forceps or vacuum through Cesarean section incision.

7 74 Exercises .. 75 Chapter summary .. 76 Case 77 Chapter 7: Breech presentation and extraction ..80 Chapter overview .. 80 Breech presentation .. 80 Breech delivery .. 82 Internal podalic version and breech extraction in transverse lie .. 86 Exercises .. 87 Chapter summary .. 88 Case study .. 89 A Guide to Obstetrical Coding 5 Chapter 8: Cesarean section ..90 Chapter overview .. 90 Indications for Cesarean section .. 90 Types of Cesarean section .. 91 Complications of Cesarean section.

8 97 Previous Cesarean section .. 99 Exercises .. 105 Chapter summary .. 106 Case study .. 107 Chapter 9: Postpartum hemorrhage .. 108 Chapter overview .. 108 Definition of postpartum hemorrhage .. 108 Causes and classification of postpartum hemorrhage (4 Ts) .. 110 Diagnosis typing of PPH .. 116 Preventing postpartum hemorrhage .. 117 Management of postpartum hemorrhage .. 117 Exercises .. 123 Chapter summary .. 124 Case study .. 125 Chapter 10: Fetal distress .. 127 Chapter overview.

9 127 Passage of meconium in cephalic presentation .. 127 Fetal heart rate (FHR) anomalies .. 128 Classifying fetal distress Mother .. 129 Fetal acidemia .. 132 Classifying acidemia Newborn .. 132 Exercises .. 135 Chapter summary .. 135 Case 136 Appendices .. 138 Appendix A: Answers to case studies and practice exercises .. 138 Appendix B: References .. 154 A Guide to Obstetrical Coding 6 About CIHI The Canadian Institute for Health Information (CIHI) is an independent, not-for-profit organization that provides essential information on Canada s health systems and the health of Canadians.

10 We provide comparable and actionable data and information that are used to accelerate improvements in health care, health system performance and population health across Canada. Our stakeholders use our broad range of health system databases, measurements and standards, together with our evidence-based reports and analyses, in their decision-making processes. We protect the privacy of Canadians by ensuring the confidentiality and integrity of the health care information we provide. A Guide to Obstetrical Coding 7 Chapter 1: Introduction Guide overview Introduction A Guide to Obstetrical Coding is a resource that addresses some of the more complex and challenging areas of Obstetrical Coding using the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA) and the Canadian Classification of Health Interventions (CCI).