O70.21
Third degree perineal laceration during delivery, IIIa
Clinical Classification Guidelines
Inclusion Terms
- Third degree perineal laceration during delivery with less than 50% of external anal sphincter (EAS) thickness torn
Medical Intelligence & Overview
A third degree perineal laceration, classified under ICD-10 code O70.21, refers to a tear that occurs during childbirth extending through the perineum and involving the external anal sphincter muscle. Specifically, the IIIa designation indicates that less than 50% of the external anal sphincter (EAS) is torn. This injury can happen naturally during vaginal delivery, especially in cases of rapid or difficult births. Recognizing and understanding this condition is crucial for ensuring proper management and recovery for new mothers.
Causes & Symptoms
Clinical Causes: Prolonged or difficult labor Large birth weight of the baby Operational procedures like forceps or vacuum extraction First vaginal delivery or rapid delivery Use of an episiotomy, especially if extended Inadequate perineal support during delivery
Key Symptoms: Severe pain or burning sensation in the perineal area Swelling or bruising around the perineum Visible tear or bleeding in the perineal region Difficulty controlling bowel movements Discomfort or pain during sitting or walking Possible sensation of a tear extending to the anal area
Diagnostic & Treatment
Diagnosis Path: Diagnosis is usually made through a physical examination immediately after delivery. The healthcare provider will assess the extent of the tear, often using visual inspection and palpation. In certain cases, especially if the tear involves the anal sphincter, additional imaging such as endoanal ultrasound may be employed to evaluate the damage precisely. Accurate classification helps guide appropriate treatment and repair strategies.
Treatment Protocols: Management of a third degree perineal laceration involves surgical repair performed shortly after delivery. The goal is to accurately sew the torn muscles and tissues to restore normal anatomy and function. Postoperative care focuses on pain control, preventing infection, and promoting healing. Patients may be advised on sitz baths, pelvic floor exercises, and good hygiene practices. In some cases, physiotherapy or specialized follow-up might be recommended to aid recovery and regain normal pelvic function.
Clinical Advice & FAQs
Billing Guidance
Is O70.21 a billable ICD-10 code?
Yes, O70.21 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.
Documentation
How do I report O70.21?
Clinical documentation must specify the nature of Third degree perineal laceration during delivery, IIIa and any associated comorbidities for accurate reporting.
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