Name of the Condition

• Perineal laceration during delivery, unspecified

Summary

• Perineal laceration during delivery refers to a tear that occurs in the perineal region (the area between the vagina and the anus) during childbirth. The unspecified designation suggests that the specific degree or severity of the tear is not detailed.

Causes

• The primary cause of perineal lacerations during delivery is the physical stress and pressure exerted on the perineal area as the baby passes through the birth canal during vaginal delivery.

Risk Factors

• Risk factors for perineal laceration include first-time vaginal delivery, larger baby size, prolonged labor, use of forceps or vacuum during delivery, and a history of previous perineal lacerations.

Symptoms

• Symptoms can include pain in the perineal area, swelling, bruising, and bleeding immediately after delivery.

Diagnosis

• Diagnosis is typically made through a physical examination by a healthcare provider immediately after delivery, assessing the perineal area for any tears.

Treatment Options

• Treatment may involve suturing the laceration if necessary. Pain relief options, such as ice packs, pain medication, or sitting on cushions, are provided. Perineal care instructions are given to prevent infection and promote healing.

Prognosis and Follow-Up

• The prognosis is generally good, with many women healing completely within a few weeks with appropriate care. Follow-up appointments may be scheduled to ensure proper healing and address any complications.

Complications

• Potential complications include infection, excessive bleeding, and difficulties with urination or bowel movements if severe tears occur and are not well-managed.

Lifestyle & Prevention

• While not entirely preventable, perineal massage in the weeks leading up to delivery and certain birthing positions may reduce the risk. Proper prenatal care and following recommended birthing practices can also be beneficial.

When to Seek Professional Help

• Seek immediate medical attention if there is heavy bleeding, signs of infection (e.g., fever, red or swollen skin), or severe, persistent pain after childbirth.

Additional Resources

• March of Dimes: www.marchofdimes.org

• American College of Obstetricians and Gynecologists: www.acog.org

Tips for Medical Coders

• Ensure documentation specifies that the laceration occurred during delivery and is unspecified in severity.
• Avoid miscategorizing perineal lacerations that have been specifically graded or classified under more precise ICD codes.