Birth Trauma: Discharge Abstract Database
Discharge Abstract Database (DAD) Codes included in this clinical category:
A04: Birth Trauma
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Concept |
Injuries to the newborn during non-instrumented vaginal delivery identified during the birth episode of care. |
|
Notes |
Refer to D04: Birth Trauma for injuries during instrument-assisted or Caesarean section delivery. |
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Selection criteria |
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Codes |
Code descriptions |
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P10–P15 |
Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND Entry Code N* |
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Exclusions
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Codes |
Code descriptions |
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P10.- |
Intracranial laceration and hemorrhage due to birth injury |
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P11.- |
Other birth injuries to central nervous system |
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P12.- |
Birth injury to scalp |
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P13.- |
Birth injury to skeleton |
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P14.- |
Birth injury to peripheral nervous system |
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P15.- |
Other birth injuries |
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Additional Codes |
Exclusions |
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P07.- |
Disorders related to short gestation and low birth weight, not elsewhere classified |
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P10.–§ |
Intracranial laceration and hemorrhage due to birth injury |
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P11.1§ |
Other specified brain damage due to birth injury |
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P11.2§ |
Unspecified brain damage due to birth injury |
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P96.4 |
Termination of pregnancy, affecting fetus and newborn |
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Q00–Q07 |
Congenital malformations of the nervous system (refer to Appendix A) |
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Q65–Q79 |
Congenital malformations and deformations of the musculoskeletal system (refer to Appendix A) |
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5.CA.20.^^ |
Pharmacotherapy (in preparation for), termination of pregnancy |
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5.CA.24.^^ |
Preparation by dilating cervix (for), termination of pregnancy |
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5.CA.88.^^ |
Pharmacological termination of pregnancy |
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5.CA.89.^^ |
Surgical termination of pregnancy |
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5.CA.93.^^ |
Surgical removal of extrauterine pregnancy |
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5.MD.53.^^ |
Forceps traction and rotation delivery |
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5.MD.54.^^ |
Vacuum traction delivery |
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5.MD.55.^^ |
Combination of vacuum and forceps delivery |
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5.MD.56.NN |
Breech delivery without episiotomy, partial breech extraction [assisted breech delivery] with forceps to aftercoming head |
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5.MD.56.PC |
Breech delivery with episiotomy, partial breech extraction [assisted breech delivery] with forceps to aftercoming head |
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5.MD.56.NR |
Breech delivery without episiotomy, total breech extraction with forceps to aftercoming head |
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5.MD.56.PF |
Breech delivery with episiotomy, total breech extraction with forceps to aftercoming head |
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5.MD.56.NW |
Breech delivery without episiotomy, unspecified breech extraction with forceps to aftercoming head |
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5.MD.56.PJ |
Breech delivery with episiotomy, unspecified breech extraction with forceps to aftercoming head |
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5.MD.60.^^ |
Caesarean section delivery |
*Entry Code N indicates an infant was born alive in the reporting facility.
† Due to the unavailability of chart numbers for Prince Edward Island, birth trauma with and without the assistance of instruments cannot be differentiated; therefore, all birth trauma in P.E.I. is included in this group regardless of the use of instruments or method of delivery.
‡ Newborns whose mothers are discharged from acute care facilities in a different fiscal year cannot be linked to the mothers' records; therefore, a few birth trauma cases that belong to D04 could be misclassified to A04 as the linkage is done within a fiscal year. A fiscal year is defined based on discharged date from April 1 of the current year to March 31 of the subsequent year.
§ These codes are part of the selection criteria, except when preterm and low birth weight is also coded. See the exclusion terms in the selection criteria section above.
D04: Birth Trauma
|
Concept |
Injuries to the newborn during an instrument-assisted or Caesarean section delivery |
|
Notes |
Refer to A04: Birth Trauma for injuries during vaginal delivery without the assistance of instruments. |
|
Selection criteria |
|
|
Codes |
Code descriptions |
|
P10–P15 |
Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND Entry Code N* AND Newborns whose mother’s abstract has 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.^^)‡ |
|
Exclusions |
|
|
Codes |
Code descriptions |
|
P10.- |
Intracranial laceration and hemorrhage due to birth injury |
|
P11.- |
Other birth injuries to central nervous system |
|
P12.- |
Birth injury to scalp |
|
P13.- |
Birth injury to skeleton |
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P14.- |
Birth injury to peripheral nervous system |
|
P15.- |
Other birth injuries |
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Additional Codes |
Inclusions |
|
5.MD.53.^^ |
Forceps traction and rotation delivery |
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5.MD.54.^^ |
Vacuum traction delivery |
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5.MD.55.^^ |
Combination of vacuum and forceps delivery |
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5.MD.56.NN |
Breech delivery without episiotomy, partial breech extraction [assisted breech delivery] with forceps to aftercoming head |
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5.MD.56.PC |
Breech delivery with episiotomy, partial breech extraction [assisted breech delivery] with forceps to aftercoming head |
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5.MD.56.NR |
Breech delivery without episiotomy, total breech extraction with forceps to aftercoming head |
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5.MD.56.PF |
Breech delivery with episiotomy, total breech extraction with forceps to aftercoming head |
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5.MD.56.NW |
Breech delivery without episiotomy, unspecified breech extraction with forceps to aftercoming head |
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5.MD.56.PJ |
Breech delivery with episiotomy, unspecified breech extraction with forceps to aftercoming head |
|
5.MD.60.^^ |
Caesarean section delivery |
|
Additional Codes |
Exclusions |
|
P07.- |
Disorders related to short gestation and low birth weight, not elsewhere classified |
|
P10.–§ |
Intracranial laceration and hemorrhage due to birth injury |
|
P11.1§ |
Other specified brain damage due to birth injury |
|
P11.2§ |
Unspecified brain damage due to birth injury |
|
P96.4 |
Termination of pregnancy, affecting fetus and newborn |
|
Q00–Q07 |
Congenital malformations of the nervous system (refer to Appendix A) of the Hospital Harm Indicator General Methodology Notes |
|
Q65–Q79 |
Congenital malformations and deformations of the musculoskeletal system (refer to Appendix A) of the Hospital Harm Indicator General Methodology Notes |
*Entry Code N indicates an infant was born alive in the reporting facility.
† Due to the unavailability of chart numbers for Prince Edward Island, birth trauma with and without the assistance of instruments cannot be differentiated; therefore, all birth trauma in P.E.I. is included in this group regardless of the use of instruments or method of delivery.
‡ Newborns whose mothers are discharged from acute care facilities in a different fiscal year cannot be linked to the mothers' records; therefore, a few birth trauma cases that belong to D04 could be misclassified to A04 as the linkage is done within a fiscal year. A fiscal year is defined based on discharged date from April 1 of the current year to March 31 of the subsequent year.
§ These codes are part of the selection criteria, except when preterm and low birth weight is also coded. See the exclusion terms in the selection criteria section above.
Birth Trauma
