Hospital Harm: Obstetric Trauma
Lacerations are common after vaginal birth. Trauma can occur on the cervix, vagina, and vulva, including the labial, periclitoral, and periurethral regions, and the perineum (American College of Obstetricians and Gynecologists (ACOG), 2018). A woman's safety during childbirth can be assessed by looking at potentially avoidable tearing of the perineum (Organization for Economic Co-operation and Development (OECD), 2019) and other obstetrical injuries to the pelvic organs during vaginal deliveries. While it is not possible to prevent these types of tears in all cases, they can be reduced by appropriate labour management and high-quality obstetric care (OECD, 2019).
- Topics
- Patient safety
- Hospital harm
- Audience
Point of care provider
Quality or safety improvement lead
Policy advisor or analyst
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Goal
Reduce the incidence of obstetric trauma captured in this clinical group.
Overview
Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.
Obstetric anal sphincter injuries (also known as Obstetric Anal Sphincter Injury - OASI)
Perineal trauma occurs either spontaneously with vaginal delivery or secondarily as an extension to an episiotomy. Severe perineal trauma can involve damage to the anal sphincters and anal mucosa. Obstetric anal sphincter injuries (OASIS) refers to third- and fourth-degree perineal tears. Third degree tears involve a partial or complete disruption of the anal sphincter complex which includes the external anal sphincter and the internal anal sphincter. Fourth degree tears involve disruption of the anal mucosa in addition to division of the anal sphincter complex (Aasheim et al., 2017; Harvey & Pierce, 2015). The table below lists the classification of OASIS from first to fourth degree.
The list below lists the classification of OASIS from first to fourth degree:
First degree: Injury to perineal skin only
Second degree: Injury to perineum involving perineal muscles but not involving the anal sphincter
Third degree: Injury to perineum involving the anal sphincter complex:
3a: Less than 50% of external anal sphincter (EAS) thickness torn
3b: More than 50% of EAS thickness torn
3c: Both EAS and internal anal sphincter (IAS) torn
Fourth degree: Injury to perineum involving the anal sphincter complex (EAS and IAS) and anal epithelium
Importance to Patients and Families
In Canada, there are approximately to 380,000 births each year (Statistics Canada, n.d.). Although many births may appear to be 'normal' and uneventful, data portray a different scenario. According to data from the OECD, of the 23 reporting countries in 2017, Canada had the highest reported rate of obstetric trauma for both vaginal delivers with and without instruments (OECD, 2019).
Obstetric trauma is among the most common adverse events in Canada. Obstetric trauma, including third degree and greater lacerations which may result in longer lengths of stay for mothers, as well as chronic complications such as fecal incontinence, dyspareunia, perineal pain and other pelvic floor disorders (CIHI, n.d.). The immediate and long term psychological and physical impact of these complications on the mother and family are difficult to calculate. Many of the adverse events that occur are the result of system failures, rather than individual failures. It is now known that by creating a more reliable system of care we will be able to prevent, mitigate, and identify opportunities to prevent harm (Institute for Healthcare Improvement (IHI), 2012).
Patient Story
Here are videos of three women who have anonymously spoken out about their experience of suffering from the effects of an OASIS (RCOG, n.d.).
Clinical and System Reviews, Incident Analyses
Given the broad range of potential causes of complications from obstetric trauma, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.
Occurrences of harm are often complex with many contributing factors. Organizations need to:
Measure and monitor the types and frequency of these occurrences.
Use appropriate analytical methods to understand the contributing factors.
Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
Have mechanisms in place to mitigate consequences of harm when it occurs.
To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for conducting chart audits and analysis methods are included in the Hospital Harm Improvement Resource Introduction.
If your review reveals that your cases of OB Trauma are related linked to specific processes or procedures, you may find these resources helpful:
American College of Obstetricians and Gynecologists (ACOG). https://www.acog.org/
Prevention and Management of Obstetric Lacerations at Vaginal Delivery. ACOG Practice Bulletin, Clinical Management Guidelines for Obstetrician–Gynecologists. Number 198, September 2018.
Operative Vaginal Delivery. ACOG Practice Bulletin, Clinical Management Guidelines for Obstetrician–Gynecologists. Number 154, November 2015.
Vaginal Birth After Cesarean Delivery. ACOG Practice Bulletin, Clinical Management Guidelines for Obstetrician–Gynecologists. Number 2015, February 2019.
Association of Women's Health, Obstetric and Neonatal Nurses. www.awhonn.org
Association of Ontario Midwives. https://www.ontariomidwives.ca/
Vaginal birth after Previous Low-Segment Caesarean Section, Clinical Practice Guideline, 14. September 2011. https://www.ontariomidwives.ca/sites/default/files/CPG%20full%20guidelines/CPG-Vaginal-birth-after-caesarean-section-PUB.pdf
Ontario Health. https://www.hqontario.ca/
Vaginal Birth After Caesarean: (VBAC)-Quality Standard-https://www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/View-all-Quality-Standards/Vaginal-Birth-After-Caesarean-VBAC
National Institute for Health and Care Excellence (NICE). https://www.nice.org.uk/
Intrapartum care for healthy women and babies. Clinical guideline 190. Published date: December 2014, Last updated: February 2017. https://www.nice.org.uk/guidance/cg190
Caesarean section. Clinical guideline 132. Published date: November 2011 Last updated: September 2019. https://www.nice.org.uk/guidance/cg132
Royal College of Obstetricians and Gynaecologists (RCOG). https://www.rcog.org.uk/
The OASI Care Bundle Project- https://www.rcog.org.uk/en/guidelines-research-services/audit-quality-improvement/oasi-care-bundle/
The Management of Third- and Fourth-Degree Perineal Tears- Green-top Guideline No. 29, June 2015
Birth After Previous Caesarean Birth-Green-top Guideline No. 45, October 2015
Society of Obstetricians and Gynaecologists of Canada (SOGC). https://sogc.org/Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair. SOGC Clinical Practice Guideline. No. 330, December 2015.
Assisted Vaginal Birth. SOGC Clinical Practice Guideline. No. 381, June 2019.
Trial of Labour After Caesarean. SOGC Clinical Practice Guideline. No. 382, July 2019.
World Health Organization (WHO). https://www.who.int/
WHO Safe Childbirth Checklist. https://www.who.int/patientsafety/implementation/checklists/childbirth/en/
Measures
Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). In selecting your measures, consider the following:
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You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.
Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.
Whenever possible, use measures you are already collecting for other programs.
Try to include both process and outcome measures in your measurement scheme.
Discharge Abstract Database
Discharge Abstract Database (DAD) Codes included in this clinical category:
A03: Obstetric Trauma
Concept: Third- or fourth-degree perineal lacerations or other obstetric injuries to pelvic organs during a non-instrumented vaginal delivery identified during the delivery episode of care.
Notes: Refer to D03: Obstetric Trauma for obstetric trauma during an instrument-assisted vaginal delivery.
Code: Condition
O70.201*: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
O70.211†: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
O70.221†: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
O70.231†: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
O70.281†: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
O70.291†: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
O70.301: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
O71.181: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
O71.301: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
O71.401: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
O71.501: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
O71.601: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
5.PC.80.JH: Identified as an intervention AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–, O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
5.PC.80.JJ: Identified as an intervention AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–, O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
5.PC.80.JR: Identified as an intervention AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–, O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
5.PC.80.JQ: Identified as an intervention AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–, O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
5.PC.80.JU: Identified as an intervention AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–, O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
5.PC.80.JL: Identified as an intervention AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–, O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– on the same abstract
* Before 2018–2019 data
† Starting with 2018–2019 data
Exclusions
Abstracts with intervention codes for instrument-assisted or Caesarean section delivery (5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW, 5MD.56.PJ or 5.MD.60.^^)
Abstracts indicating a pregnancy with abortive outcome (O04. – OR 5.CA.20.^^, 5.CA.24.^^, 5.CA.88.^^, 5.CA.89.^^ or 5.CA.93.^^, not abandoned)
Discharge Abstract Database (DAD) Codes included in this clinical category:
A03: Obstetric Trauma
Concept: Third- or fourth-degree perineal lacerations or other obstetric injuries to pelvic organs during a non-instrumented vaginal delivery identified during the delivery episode of care.
Notes: Refer to D03: Obstetric Trauma for obstetric trauma during an instrument-assisted vaginal delivery.
Code: Code Description
O70.201: Third degree perineal laceration during delivery; delivered with or without mention of antepartum condition
O70.211: Third degree perineal laceration during delivery, type 3a, so described, delivered, with or without mention of antepartum condition
O70.221: Third degree perineal laceration during delivery, type 3b, so described, delivered, with or without mention of antepartum condition
O70.231: Third degree perineal laceration during delivery, type 3c, so described, delivered, with or without mention of antepartum condition
O70.281: Third degree perineal laceration during delivery, other specified type, delivered, with or without mention of antepartum condition
O70.291: Third degree perineal laceration during delivery, unspecified type, delivered, with or without mention of antepartum condition
O70.301: Fourth degree perineal laceration during delivery; delivered with or without mention of antepartum condition
O71.181: Other rupture of uterus during labour; delivered with or without mention of antepartum condition
O71.301: Obstetric laceration of cervix; delivered with or without mention of antepartum condition
O71.401: Obstetric high vaginal laceration; delivered with or without mention of antepartum condition
O71.501: Other obstetric injury to pelvic organs; delivered with or without mention of antepartum condition
O71.601: Obstetric damage to pelvic joints and ligaments; delivered with or without mention of antepartum condition
5.PC.80.JH: Surgical repair, postpartum of obstetric laceration of corpus uteri [body of uterus]
5.PC.80.JJ: Surgical repair, postpartum of current obstetric laceration of cervix occurring at vaginal delivery
5.PC.80.JR: Surgical repair, postpartum of current obstetric laceration of bladder and urethra
5.PC.80.JQ: Surgical repair, postpartum of current obstetric laceration of rectum and sphincter ani
5.PC.80.JU: Surgical repair, postpartum of current obstetric high vaginal laceration
5.PC.80.JL: Surgical repair, postpartum of current obstetric laceration of broad ligament(s) of uterus
Discharge Abstract Database (DAD) Codes included in this clinical category:
A03: Obstetric Trauma
Concept: Third- or fourth-degree perineal lacerations or other obstetric injuries to pelvic organs during a non-instrumented vaginal delivery identified during the delivery episode of care.
Notes: Refer to D03: Obstetric Trauma for obstetric trauma during an instrument-assisted vaginal delivery.
Additional Codes: Inclusions
O10–O16: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O21–O26: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O28–O37: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O40–O46: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O48.–: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O60–O75: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O85–O92: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O95.–: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O98–O99: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
Z37.–: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
Discharge Abstract Database (DAD) Codes included in this clinical category:
A03: Obstetric Trauma
Concept: Third- or fourth-degree perineal lacerations or other obstetric injuries to pelvic organs during a non-instrumented vaginal delivery identified during the delivery episode of care.
Notes: Refer to D03: Obstetric Trauma for obstetric trauma during an instrument-assisted vaginal delivery.
Additional Codes: Exclusions
O04.–: Medical abortion
5.CA.20.^^: Pharmacotherapy (in preparation for), termination of pregnancy
5.CA.24.^^: Preparation by dilating cervix (for), termination of pregnancy
5.CA.88.^^: Pharmacological termination of pregnancy
5.CA.89.^^: Surgical termination of pregnancy
5.CA.93.^^: Surgical removal of extrauterine pregnancy
5.MD.53.^^: Forceps traction and rotation delivery
5.MD.54.^^: Vacuum traction delivery
5.MD.55.^^: Combination of vacuum and forceps delivery
5.MD.56.NN: Breech delivery without episiotomy, partial breech extraction [assisted breech delivery] with forceps to aftercoming head
5.MD.56.PC: Breech delivery with episiotomy, partial breech extraction [assisted breech delivery] with forceps to aftercoming head
5.MD.56.NR: Breech delivery without episiotomy, total breech extraction with forceps to aftercoming head
5.MD.56.PF: Breech delivery with episiotomy, total breech extraction with forceps to aftercoming head
5.MD.56.NW: Breech delivery without episiotomy, unspecified breech extraction with forceps to aftercoming head
5.MD.56.PJ: Breech delivery with episiotomy, unspecified breech extraction with forceps to aftercoming head
5.MD.60.^^: Caesarean section delivery
Discharge Abstract Database (DAD) Codes included in this clinical category:
D03: Obstetric Trauma
Concept: Lacerations of third degree or greater severity, or other obstetric injury to pelvic organs during an instrument-assisted vaginal delivery.
Notes:
Refer to A03: Obstetric Trauma for obstetric trauma during a non-instrumented vaginal delivery.
This clinical group does not include obstetric trauma during Caesarean section delivery.
Code: Condition
O70.201*: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
O70.211 †: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
O70.221 †: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
O70.231 †: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
O70.281 †: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
O80.291 †: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
O70.301: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
O71.181: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
O71.301: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
O71.401: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
O71.501: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
O71.601: Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
5.PC.80.JH: Identified as an intervention AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–, O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
5.PC.80.JJ: Identified as an intervention AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–, O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
5.PC.80.JR: Identified as an intervention AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–, O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
5.PC.80.JQ: Identified as an intervention AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–, O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
5.PC.80.JU: Identified as an intervention AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–, O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
5.PC.80.JL: Identified as an intervention AND O10–O16, O21–O26, O28–O37, O40–O46, O48.–, O60–, O75, O85–O92, O95.– or O98–O99 with a sixth digit of 1 or 2 or Z37.– AND intervention codes 5.MD.53.^^, 5.MD.54.^^, 5.MD.55.^^, 5.MD.56.NN, 5.MD.56.PC, 5.MD.56.NR, 5.MD.56.PF, 5.MD.56.NW or 5.MD.56.PJ on the same abstract
* Before 2018-2019 data
† Starting with 2018-2019 data
Exclusions
Abstracts with intervention codes for Caesarean section delivery (5.MD.60.^^)
Abstracts indicating a pregnancy with abortive outcome (O04.– OR 5.CA.20.^^, 5.CA.24.^^, 5.CA.88.^^, 5.CA.89.^^ or 5.CA.93.^^, not abandoned)
Discharge Abstract Database (DAD) Codes included in this clinical category:
D03: Obstetric Trauma
Concept: Lacerations of third degree or greater severity, or other obstetric injury to pelvic organs during an instrument-assisted vaginal delivery.
Notes:
Refer to A03: Obstetric Trauma for obstetric trauma during a non-instrumented vaginal delivery.
This clinical group does not include obstetric trauma during Caesarean section delivery.
Code: Code Description
O70.201: Third degree perineal laceration during delivery; delivered with or without mention of antepartum condition
O70.211: Third degree perineal laceration during delivery, type 3a, so described, delivered, with or without mention of antepartum condition
O70.221: Third degree perineal laceration during delivery, type 3b, so described, delivered, with or without mention of antepartum condition
O70.231: Third degree perineal laceration during delivery, type 3c, so described, delivered, with or without mention of antepartum condition
O70.281: Third degree perineal laceration during delivery, other specified type, delivered, with or without mention of antepartum condition
O70.291: Third degree perineal laceration during delivery, unspecified type, delivered, with or without mention of antepartum condition
O70.301: Fourth degree perineal laceration during delivery; delivered with or without mention of antepartum condition
O71.181: Other rupture of uterus during labour; delivered with or without mention of antepartum condition
O71.301: Obstetric laceration of cervix; delivered with or without mention of antepartum condition
O71.401: Obstetric high vaginal laceration; delivered with or without mention of antepartum condition
O71.501: Other obstetric injury to pelvic organs; delivered with or without mention of antepartum condition
O71.601: Obstetric damage to pelvic joints and ligaments; delivered with or without mention of antepartum condition
5.PC.80.JH: Surgical repair, postpartum of obstetric laceration of corpus uteri [body of uterus]
5.PC.80.JJ: Surgical repair, postpartum of current obstetric laceration of cervix occurring at vaginal delivery
5.PC.80.JR: Surgical repair, postpartum of current obstetric laceration of bladder and urethra
5.PC.80.JQ: Surgical repair, postpartum of current obstetric laceration of rectum and sphincter ani
5.PC.80.JU: Surgical repair, postpartum of current obstetric high vaginal laceration
5.PC.80.JL: Surgical repair, postpartum of current obstetric laceration of broad ligament(s) of uterus
Discharge Abstract Database (DAD) Codes included in this clinical category:
D03: Obstetric Trauma
Concept: Lacerations of third degree or greater severity, or other obstetric injury to pelvic organs during an instrument-assisted vaginal delivery.
Notes:
Refer to A03: Obstetric Trauma for obstetric trauma during a non-instrumented vaginal delivery.
This clinical group does not include obstetric trauma during Caesarean section delivery.
Additional Codes: Inclusions
5.MD.53.^^: Forceps traction and rotation delivery
5.MD.54.^^: Vacuum traction delivery
5.MD.55.^^: Combination of vacuum and forceps delivery
5.MD.56.NN: Breech delivery without episiotomy, partial breech extraction [assisted breech delivery] with forceps to aftercoming head
Discharge Abstract Database (DAD) Codes included in this clinical category:
D03: Obstetric Trauma
Concept: Lacerations of third degree or greater severity, or other obstetric injury to pelvic organs during an instrument-assisted vaginal delivery.
Notes:
Refer to A03: Obstetric Trauma for obstetric trauma during a non-instrumented vaginal delivery.
This clinical group does not include obstetric trauma during Caesarean section delivery.
Additional Codes: Exclusions
5.MD.60.^^: Caesarean section delivery
O10–O16: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O21–O26: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O28–O37: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O40–O46: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O48.–: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O60–O75: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O85–O92: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O95.–: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
O98–O99: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
Z37.–: Outcome of delivery (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
Success Stories
Managing Obstetrical Risk Efficiently (MOREOB) in Northern Health
British Columbia Patient Safety & Quality Council-Quality Award Winner (2009)
The MOREOB program launched in 2006, is a comprehensive patient safety, professional development and performance improvement program for hospital caregivers and administrators providing obstetrical care in Northern Health.
Over the past four years, health care providers and administrators working in obstetrics have come together as a cohesive team with a shared passion and goal for putting patient safety first. Ninety-three per cent of Northern Health obstetrical healthcare providers (including physicians, midwives, nurses and administrators) are participating in the program. Evaluation of the program has found a growth in leadership capacity with safe patient care at the core. Activities within the program include environmental scans, patient satisfaction surveys, staying current with new evidence and best practices, participating in workshops, and competency drills. The program structure is based on proven principles of High Reliability Organizations, including:
Patient safety is the priority and everyone's responsibility.
Communication is highly valued.
Operations are a team effort.
Hierarchy disappears in an emergency.
Emergencies are rehearsed.
Reviews with all types of health care providers are routinely held. The MOREOB program's Annual Cultural Assessment for 2009 revealed that the participants had an improved sense of work culture, including: open communication with respect to patients and general knowledge; valuing each other's knowledge-base and skills sets; and an improved sense of teamwork. An improvement in staff retention and recruitment has been seen in all sectors.
Statistical information from the B.C. Perinatal Health Program database shows improved statistics on the number of: labour inductions, mothers who received an epidural, intermittently listening to the unborn baby's heart during labour (auscultation), number of Caesarean-section deliveries, and newborns with cord blood gases after delivery.
Changes and efforts that were made to achieve these outcomes and spread the initiative included the following:
promoting the annual program components of the MOREOB program for all participants;
monthly regional obstetrical rounds via videoconference;
development of a Regional Perinatal Council, including quality;
practice working groups;
growing communities of practice;
design of a template to support Council development for other disciplines, such as critical care, emergency care and long-term care; and
annual planning conference for core team leaders. (BC Patient Safety & Quality Council, 2009)
References
Aasheim V, Nilsen AB, , Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma (Review). Cochrane Database Syst Rev. 2017; 6:CD006672. doi: 10.1002/14651858.CD006672.pub3. doi: 10.1002/14651858.CD006672.pub3
American College of Obstetricians and Gynecologists (ACOG), committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 198: Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstet Gynecol. 2018;132(3):e87-e102. doi: 10.1097/AOG.0000000000002841
American College of Obstetricians and Gynecologists (ACOG), committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery. Obstet Gynecol. 2019;133(2):e110-e127. doi: 10.1097/AOG.0000000000003078
Andersen MM, Thisted DLA, Amer-Wahlin I, Krebs L. Can Intrapartum Cardiotocography Predict Uterine Rupture among Women with Prior Caesarean Delivery?: A Population Based Case-Control Study. PLoS One. 2016;11(2):e0146347. doi: 10.1371/journal.pone.0146347
BC Patient Safety & Quality Council. Quality Awards 2009. Managing Obstetrical Risk Efficiently (MOREOB): Northern Health. BC Patient Safety & Quality Council; 2009. https://bcpsqc.ca/quality-awards/winners/managing-obstetrical-risk-efficiently-moreob-northern-health/ Accessed April 21, 2020.
Canadian Institute for Health Information (CIHI). Canada continues to lag behind other OECD countries on measures of patient safety. Ottawa, ON: CIHI; 2019a. http://www.cihi.ca/en/canada-continues-to-lag-behind-other-oecd-countries-on-measures-of-patient-safety
Canadian Institute for Health Information (CIHI). Indicator library: Obstetric trauma (with instrument). CIHI; n.d. http://indicatorlibrary.cihi.ca/pages/viewpage.action?pageId=5111843
Canadian Institute for Health Information (CIHI). OECD Interactive Tool: International Comparisons — Patient Safety: OB Trauma: No Instrument: Provincial comparison with all OECD countries, 2017 or most recent year. CIHI. Published December 13, 2019b. http://www.cihi.ca/en/oecd-interactive-tool-international-comparisons-patient-safety. Accessed April 20, 2020.
Dy J, DeMeester S, Lipworth H, Barrett J. No. 382-Trial of Labour After Caesarean. J Obstet Gynaecol Can. 2019;41(7):992-1011. doi:10.1016/j.jogc.2018.11.008
Harvey MA, Pierce M. No. 330 Obstetrical anal sphincter injuries (OASIS): Prevention, recognition, and repair. J Obstet Gynaecol Can. 2015;37(12):1131–1148. Erratum. doi: 10.1016/j.jogc.2016.02.004
Health Quality Ontario (HQO). Vaginal birth after Caesarean (VBAC): care for people who have had a Caesarean birth and are planning their next birth. HQO. Published 2018. https://www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/View-all-Quality-Standards/Vaginal-Birth-After-Caesarean-VBAC. Accessed April 21, 2020.
Hobson S, Cassell K, Windrim R, Cargill Y. No. 381-Assisted Vaginal Birth. J Obstet Gynaecol Can. 2019;41(6):870-882. doi: 10.1016/j.jogc.2018.10.020
Institute for Healthcare Improvement (IHI). How-to Guide: Prevent Obstetrical Adverse Events. Cambridge, MA: IHI; 2012. http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventObstetricalAdverseEvents.aspx.
Melamed N, Ben-Haroush A, Chen R, Kaplan B, Yogev Y. Intrapartum cervical lacerations: Characteristics, risk factors, and effects on subsequent pregnancies. American Journal of Obstetrics and Gynecology. 2009;200(4):388.e1-388.e4. doi: 10.1016/j.ajog.2008.10.034
Moldenhauer JS. Uterine Rupture. Merck Manual. January 2020. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/abnormalities-and-complications-of-labor-and-delivery/uterine-rupture. Accessed April 21, 2020.
Organization for Economic Co-operation and Development (OECD). Health at a Glance 2019: OECD Indicators. Paris, FR: OECD Publishing; 2019. doi: 10.1787/4dd50c09-en
Royal College of Obstetricians and Gynaecologists (RCOG). The Management of Third- and Fourth-Degree Perineal Tears. Royal College of Obstetricians and Gynaecologists; 2015. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-29.pdf
Statistics Canada. Table 17-10-0016-01. Estimates of births, by sex, annual. Ottawa, ON: Statistics Canada; n.d. doi: 10.25318/1710001601-eng. Accessed April 20, 2020.
Wong LF, Wilkes J, Korgenski K, Varner MW, Manuck TA. Intrapartum cervical laceration and subsequent pregnancy outcomes. AJP Rep. 2016;6(3):e318-323. doi: 10.1055/s-0036-1592198
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