Name of the Condition

• Obstetric High Vaginal Laceration Alone
• ICD Code: O71.4

Summary

An obstetric high vaginal laceration is a tear that occurs in the upper part of the vaginal wall during childbirth. This type of injury can happen during a complicated or forceful delivery and requires medical attention for effective healing.

Causes

• Traumatic delivery involving forceps or vacuum extraction.
• Rapid delivery or labor where the tissues may not have enough time to stretch adequately.
• Macrosomia, where the baby is larger than average.

Risk Factors

• First-time vaginal births (primiparity).
• Use of instrumental assistance during delivery, such as forceps or vacuum.
• Prolonged second stage of labor.
• Large baby size.
• Episiotomy, a surgical cut made at the opening of the vagina during childbirth.

Symptoms

• Pain in the vaginal area.
• Swelling or bruising around the vaginal opening.
• Excessive bleeding post-delivery.
• Difficulty or pain while urinating.

Diagnosis

• Physical examination by a healthcare professional immediately post-delivery to evaluate the extent of the laceration.
• In some cases, imaging may be employed to assess associated injuries.

Treatment Options

• Surgical repair conducted immediately post-delivery to stitch the laceration.
• Pain relief management using analgesics.
• Use of antibiotics to prevent infection in some cases.

Prognosis and Follow-Up

• With appropriate treatment, healing is often complete within a few weeks.
• Follow-up visits are crucial for ensuring proper healing and managing any discomfort.

Complications

• Infection if the laceration is not adequately treated.
• Potential for excessive scar tissue formation, affecting future deliveries.
• Postpartum bleeding or hemorrhage.

Lifestyle & Prevention

• Controlled perineal support during delivery may help prevent such lacerations.
• Birth plans discussing the possibility of instrumental delivery.

When to Seek Professional Help

• If there is persistent or severe pain not relieved by pain medication.
• Signs of infection like fever, foul-smelling discharge, or increased pain and swelling.
• Excessive or sustained bleeding post-delivery.

Additional Resources

• American College of Obstetricians and Gynecologists (ACOG)
• International Childbirth Education Association (ICEA)

Tips for Medical Coders

• Ensure accuracy in documenting the ICD-10 code O71.4 for medical records.
• Confirm the laceration is classified as "high vaginal" to distinguish from other obstetric lacerations.
• Verify documentation specifies the injury occurred during delivery.