[WWW - 2023.07.31]

Data Element Detail

Female-state of perineum following birth
Identifying and Definitional Attributes
QH 040023 v6
Data Element
Data Element
Draft
12-Dec-2018
Standard
Information Management Strategic Governance Committee (IMSGC), Queensland Health
01-Jul-2019
The state of a female's perineum following birth.
Queensland Perinatal data collection (QPDC)
Perineal status
Postpartum perineal status
Representational Attributes
Numeric Character
Code
N(2)
2
2
Permissible Values

Permissible_values

CodeDescription
021st degree laceration/vaginal graze
032nd degree laceration
043rd degree laceration
054th degree laceration
06Episiotomy
98Other
Supplementary Values

Supplemenary_values

CodeDescription
99Not stated/unknown
Collection and Usage Attributes
Multiple entries of permissible values are allowed.

Code 02 1st degree laceration/vaginal graze
Graze, laceration, rupture or tear of the perineal skin during delivery that may be considered to be slight or that involves one or more of the following structures:
- fourchette
- labia
- periurethral tissue (excluding involvement of urethra)
- vagina, low
- vulva.

Excludes high vaginal wall (middle) (upper third of vaginal wall) or vaginal sulcus. Should not be recorded in conjunction with any other code except for code 06 Episiotomy.

Code 03 2nd degree laceration
Perineal laceration, rupture or tear as in code 02 occurring during delivery, also involving:
- pelvic floor
- perineal muscles
- vaginal muscles.

Excludes laceration involving the anal sphincter. Should not be recorded in conjunction with any other code except for code 06 Episiotomy.

Code 04 3rd degree laceration
Perineal laceration, rupture or tear as in code 03 occurring during delivery, also involving:
- anal sphincter (excluding involvement of anal or rectal mucosa)
- rectovaginal septum
- sphincter not otherwise specified (NOS).

Excludes laceration involving the anal or rectal mucosa. Should not be recorded in conjunction with any other code except for code 06 Episiotomy.

Code 05 4th degree laceration
Perineal laceration, rupture or tear as in code 04 occurring during delivery, also involving:
- anal mucosa
- rectal mucosa.

Should not be recorded in conjunction with any other code except for code 06 Episiotomy.

Code 06 Episiotomy
Surgical incision into the perineum and vagina to assist delivery.

Code 98 Other perineal laceration, rupture or tear
A type of perineal damage not defined above was sustained during delivery. May include haematoma or unspecified perineal tear. Should not be recorded in conjunction with any other code except for code 06 Episiotomy.

Code 99 Not stated/unknown
The type of perineal damage sustained during birth is not stated or unknown.
Queensland Perinatal Data Collection (QPDC):
If Queensland Perinatal Data Collection (QPDC)-baby's code type = V (Perineal status code) then:
Validate against list of Perineum damage codes.
Record must exist if Female (mother)-perineal damage during birth indicator = 2 (Yes).
Record must not exist if Female (mother)-perineal damage during birth indicator = 1 (No).
In the case of multiple births this data element should be recorded for each baby born.

If a laceration occurred during delivery and an episiotomy was performed, both the degree of laceration and the episiotomy should be recorded. If an episiotomy is performed, the perineum cannot be intact.

While 4th degree laceration is more severe than an episiotomy, this category has not been placed in order of clinical significance within the value domain.

For national reporting of the Female-postpartum perineal status (NHDD) data element the following mapping occurs:
Code 02 1st degree laceration/vaginal graze is mapped to code 2 1st degree laceration/vaginal graze.
Code 03 2nd degree laceration is mapped to code 3 2nd degree laceration.
Code 04 3rd degree laceration is mapped to code 4 3rd degree laceration.
Code 05 4th degree laceration is mapped to code 7 4th degree laceration.
Code 06 Episiotomy is mapped to code 5 Episiotomy.
Code 98 Other perineal laceration, rupture or tear is mapped to code 88 Other perineal laceration, rupture or tear.
Code 99 Not stated/unknown is mapped to code 99 Not stated/inadequately described.
Perineal laceration (tear) may cause significant maternal morbidity in the postnatal period. Episiotomy is an indicator of management during labour and, to some extent, of obstetric intervention.
Relational Attributes
Related Metadata References

Related Metadata References_IR

  • 1 - 2
ViewRelationshipMetadata Item TypeMetadata Item SubtypeNameIdentifier & VersionApproval Status
SupersedesData ElementData ElementFemale (mother)-state of perineum following birthQH 040023 Version 5Current
Is qualified byData ElementData ElementFemale (mother)-perineal damage during birth indicatorQH 041678 Version 1Current
Implementation in Metadata Sets

Implemented

  • 1 - 3
ViewMetadata Item TypeMetadata Item SubtypeNameIdentifer & VersionObligationApproval StatusEffective FromEffective To
Information AssetData CollectionQueensland Perinatal Data Collection (QPDC)QH 020003 Version 2ConditionalCurrent01-Jul-2019
Data Supply RequirementHHS Service AgreementQueensland Perinatal Data Collection (QPDC) Baby Data Supply Requirement (DSR) 2019-2020QH 020570 Version 1ConditionalSuperseded01-Jul-201930-Jun-2020
Data Supply RequirementHHS Service AgreementQueensland Perinatal Data Collection (QPDC) Baby Data Supply Requirement (DSR) 2020-2021QH 020700 Version 1ConditionalSuperseded01-Jul-202030-Jun-2021
Source and Reference Attributes
Australian Institute of Health and Welfare
METeOR data elements:
Female-postpartum perineal status, code N[N], identifier 695631, Health standard 12/12/2018 https://meteor.aihw.gov.au/content/index.phtml/itemId/695391/meteorItemView/long
Female-postpartum perineal status, code N[N], identifier 717924, Health standard 20/11/2019 https://meteor.aihw.gov.au/content/index.phtml/itemId/717924/meteorItemView/long
CRDI; CRDI QPDC; Perineal status; Perineum;