Obstetric Data Definitions Issues and Rationale for Change DELIVERY

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1 Below are the refined definitions, identified issues, and rationale for the language presented in the refined definitions in the Delivery category. This document is intended to provide an overview and opportunity to review the proposed changes prior to submitting comments in the Public Comment period. Once you are ready to comment, click here for the Public Comment form for Delivery. All comments must be submitted in the Public Comment form. #2 Date of Delivery The fetus(es) date(s) of delivery. Multiple dates of delivery; is it measured from the first baby or last? How to deal with twins/multiples For Spontaneous Vaginal Delivery, there is no date of procedure in the Discharge Diagnosis Data set Delivery is an outcome; each baby should have his or her own delivery date if multiple pregnancy Date of delivery belongs to mother; date of birth belongs to baby Each baby in a set of multiples would have own record #3 Cesarean Delivery Extraction of the fetus(es) through an abdominal incision. Does not apply if any of the following occur: 1) Abdominal pregnancy 2) Ectopic Pregnancy Add separate data item to indicate presence of labor or no labor

2 How to deal with a ruptured uterus Delivery vs. Birth Replaced Cesarean Section with Cesarean Delivery Delivery is of just the fetus but not the placenta and membranes (thus placenta and membranes removed from the definition) Includes circumstance with a uterine rupture Not always delivering through a uterine incision (such as in the case of a rupture) the uterus #4 Primary Cesarean Delivery Extraction of the fetus(es) through an abdominal incision in a woman without a prior cesarean delivery. Does not apply if any of the following occur: 1) Abdominal pregnancy 2) Ectopic Pregnancy Types of incisions and whether or not they went through the uterus Delivery is of just the fetus but not the placenta and membranes (thus placenta and membranes removed from the definition) Decision was made to define as a means to distinguish from a Repeat Cesarean Delivery

3 #5 Repeat Cesarean Delivery Extraction of the fetus(es) through an abdominal incision in a woman who had a cesarean delivery in a previous pregnancy. Does not apply if any of the following occur: 1) Abdominal pregnancy 2) Ectopic Pregnancy How to handle cases of uterine rupture Importance of the number of prior cesareans, this needs to be indicated Does not distinguish between active labor, early labor, prodromal labor, or no labor Delivery is of just the fetus but not the placenta and membranes (thus placenta and membranes removed from the definition) Includes circumstance with a uterine rupture Not always delivering through a uterine incision (such as in the case of a rupture) the uterus #6 Vaginal Birth After Cesarean A vaginal delivery in a patient with a history of a previous cesarean delivery. Wanted to include the process of labor and birth

4 #7 Spontaneous Vaginal Delivery Delivery of the fetus through the vagina without the application of vacuum or forceps. Does not apply if the following occurs: Spontaneous Breech extraction Use of the term birth (which implies viability) versus the term delivery Retention of placenta and membranes with delivery of fetus Gestational age distinguishing a miscarriage from a birth Birth vs. Delivery - is there a gestational age when it becomes a birth? Determined need for definition to distinguish from Forceps or Vacuum Assistance Used the term Delivery so as to not imply viability #8 Vertex Presentation A cephalic presentation where the occiput is presenting in the pelvic inlet. Should specify whether position is anterior, posterior, or transverse. Occiput=vertex=cephalic, but where does Occiput Transverse go? Included note that the position within Vertex should be specified

5 #9 Malpresentation Any presentation other than a vertex presentation. Examples: Brow, face, compound, breech, hand, shoulder, etc. Discordance between cephalic versus vertex Examples of malpresentation are not comprehensive, but they don t need to be; it s anything other than vertex #10 Forceps Assistance Application of forceps to the fetal head. 1) Should specify whether successful or unsuccessful in achieving delivery. 2) This includes both cesarean and vaginal deliveries. How to differentiate between successful and unsuccessful and those that lead to a cesarean delivery? Does the use of forceps and/or vacuum become an indicator for C-section? Deleted the use of the term Operational Vaginal Delivery because the use of forceps or vacuum is a modifier, not a type of delivery. Forceps or vacuum may have been used in the process of delivery, such as the descent, but not necessarily used to deliver the baby Is modified so can occur at the time of cesarean delivery or at the time of the vaginal delivery Is modified such that the 2 modes of delivery are cesarean delivery or vaginal delivery; with or without assistance

6 #11 Vacuum Assistance Application of vacuum to the fetal head. 1) Should specify whether successful or unsuccessful in achieving delivery. 2) This includes both cesarean and vaginal deliveries. How to differentiate between successful and unsuccessful and those that lead to a cesarean delivery? Does the use of forceps and/or vacuum become an indicator for C-section? Deleted the use of the term Operative Vaginal Delivery because the use of forceps or vacuum is a modifier, not a type of delivery. Forceps or vacuum may have been used in the process of delivery, such as the descent, but not necessarily used to deliver the baby Is modified so can come at time of C-section or at the time of the vaginal delivery Is modified such that the 2 modes of delivery are cesarean birth or vaginal birth with or without assistance Use of cups omitted to be more generic #12 Perineal Lacerations 1 laceration extends into the perineal skin and may include the vaginal mucosa 2 laceration extends into the perineal body and does not involve the anal sphincter 2 laceration with capsular involvement extends into the perineal body and partially involves the anal sphincter* 3 laceration extends completely through the anal sphincter 4 laceration extends through the rectal mucosa *Frequently described as a partial 3 laceration 3rd or 4th degree laceration does not correctly include perineal lacerations or partial 3rd

7 degree laceration ; redefine to 2nd degree laceration with capsular involvement through the perennial body and starting into the anal sphincter but not going entirely through it Do not currently know how to define partial 3 laceration; added 2 laceration with capsular involvement Obstetrical trauma rating - no partial 3rd; it is more concerning from a patient perspective 3rd degree is reportable event On birth certificate would only be collecting 3 and 4 laceration Expanded beyond 3 and 4 only by defining all degrees #13 Placenta Accreta The clinical condition in which any part of the placenta invades and is inseparable from the uterine wall. Accreta may or may not be supported by pathologic findings. Different from a retained placenta (but currently coded the same) based on separation; retained placenta is separable while placenta accreta is not spontaneously separable Accreta, percreta, and increta; what about partial accreta and adherent/retained placenta? Placenta accreta complex; pathological diagnosis with hysterectomy

8 #14 Shoulder Dystocia A delivery complication that requires additional maneuvers to relieve impaction of the fetal shoulder. Identification parameters versus management How long a hangup? Does delivery using just McRoberts count as Shoulder Dystocia? Defining gentle maneuvers was difficult so it was omitted from the definition Prophylactics maneuver not included Modeled after current ACOG definition Click here for the Public Comment form for