O70.2
Third degree perineal laceration during delivery
Clinical Classification Guidelines
Inclusion Terms
- Perineal laceration, rupture or tear during delivery as in O70.1, also involving anal sphincter
- Perineal laceration, rupture or tear during delivery as in O70.1, also involving rectovaginal septum
- Perineal laceration, rupture or tear during delivery as in O70.1, also involving sphincter NOS
Excludes Type 1
- anal sphincter tear during delivery without third degree perineal laceration (O70.4)
- perineal laceration involving anal or rectal mucosa (O70.3)
Medical Intelligence & Overview
A third-degree perineal laceration is a serious tear that occurs during childbirth, involving rupture through the perineal skin, muscles, and the anal sphincter muscle. This type of injury can happen during vaginal delivery and may require medical intervention to repair. Recognizing and understanding this condition helps in ensuring proper management and recovery.
Causes & Symptoms
Clinical Causes: Use of forceps or vacuum during delivery Large-sized baby or rapid delivery Instrument-assisted delivery techniques Prolonged labor or difficult delivery Fetal macrosomia (larger-than-normal baby)
Key Symptoms: Severe pain in the perineal area during or after delivery Bleeding from the vagina Swelling or bruising around the perineum Difficulty controlling bowel movements Discomfort or pain during urination Visible or palpable tear in the perineal area
Diagnostic & Treatment
Diagnosis Path: Diagnosis is typically made through physical examination immediately after childbirth. The healthcare provider assesses the extent of the tear, checking for involvement of the anal sphincter muscles. In some cases, anoscopy or other imaging may be used to evaluate the injury more thoroughly. Accurate documentation of the extent of tissue damage is essential for guiding treatment.
Treatment Protocols: Treatment involves surgical repair of the tear, usually performed within hours after delivery to optimize healing. The procedure typically includes:
Clinical Advice & FAQs
Billing Guidance
Is O70.2 a billable ICD-10 code?
Yes, O70.2 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.
Documentation
How do I report O70.2?
Clinical documentation must specify the nature of Third degree perineal laceration during delivery and any associated comorbidities for accurate reporting.
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