O70.23
Third degree perineal laceration during delivery, IIIc
Clinical Classification Guidelines
Inclusion Terms
- Third degree perineal laceration during delivery with both external anal sphincter (EAS) and internal anal sphincter (IAS) torn
Medical Intelligence & Overview
A third degree perineal laceration, classified as ICD-10 code O70.23, refers to a significant tear that occurs during childbirth. This type of injury involves the tearing of the perineum—a stretch of tissue between the vaginal opening and the anus—and extends through the muscles surrounding the anus, specifically affecting both the external anal sphincter (EAS) and the internal anal sphincter (IAS). The most severe of perineal tears, this injury is common during vaginal deliveries, especially those involving a large baby, rapid labor, or instrumental assistance like forceps. Prompt recognition and appropriate repair are crucial for healing, but the laceration's complexity requires specialized medical support to prevent complications.
Causes & Symptoms
Clinical Causes: Rapid or prolonged labor leading to increased perineal stretching Use of instrumental delivery methods such as forceps or vacuum extraction Large for gestational age babies causing more extensive tissue stretching Fetal malposition or abnormal positioning causing difficulty during delivery Previous vaginal deliveries with perineal trauma Inadequate perineal support or poor tissue elasticity
Key Symptoms: Severe pain around the perineal area, especially during and after delivery Bleeding from the perineum Difficulty controlling bowel movements or feelings of a bulge or tear in the perineal region Swelling and tenderness around the perineum Discharge or signs of infection if the wound is not healing properly Potential sensation of saddle anesthesia or altered rectal sensation
Diagnostic & Treatment
Diagnosis Path: Diagnosis of a third degree perineal laceration is primarily made through a physical examination after delivery. Healthcare providers look for tears extending through the perineum and involving the anal sphincters. They may also assess the extent of injury through gentle palpation, digital rectal examination, or ultrasound if necessary. Accurate assessment helps determine the appropriate repair approach and prevent future complications such as incontinence or infection.
Treatment Protocols: Treatment involves immediate repair of the torn tissues by a skilled healthcare professional. The repair typically includes:
Clinical Advice & FAQs
Billing Guidance
Is O70.23 a billable ICD-10 code?
Yes, O70.23 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.
Documentation
How do I report O70.23?
Clinical documentation must specify the nature of Third degree perineal laceration during delivery, IIIc and any associated comorbidities for accurate reporting.
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