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Discharge Abstract Database (DAD) Codes included in this clinical category:

A04: Birth Trauma

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.

Selection criteria

 

Codes

Code descriptions

P10–P15

Identified as diagnosis type (M), (1), (2), (W), (X) or (Y) AND Entry Code N*

Exclusions

 

  1. 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.^^) OR
  2. Newborn abstracts with brain damage due to birth injury (P10.–, P11.1 or P11.2) as diagnosis type (M) or (1) AND preterm and low birth weight (P07.– ) as diagnosis type (M), (1) or (2) OR
  3. Newborn abstracts with termination of pregnancy affecting fetuses and newborns (P96.4) OR
  4. Newborn abstracts with congenital malformations of the central nervous system (Q00–Q07) as diagnosis type (M) or (1) OR
  5. Newborn abstracts with congenital malformations and deformations of the musculoskeletal system (Q65–Q79) as diagnosis type (M) or (1)

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

P14.-

Birth injury to peripheral nervous system

P15.-

Other birth injuries

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)

Q65–Q79

Congenital malformations and deformations of the musculoskeletal system (refer to Appendix A)

5.CA.20.^^

Pharmacotherapy (in preparation for), termination of pregnancy

5.CA.24.^^

Preparation by dilating cervix (for), termination of pregnancy

5.CA.88.^^

Pharmacological termination of pregnancy

5.CA.89.^^

Surgical termination of pregnancy

5.CA.93.^^

Surgical removal of extrauterine pregnancy

5.MD.53.^^

Forceps traction and rotation delivery

5.MD.54.^^

Vacuum traction delivery

5.MD.55.^^

Combination of vacuum and forceps delivery

5.MD.56.NN

Breech delivery without episiotomy, partial breech extraction [assisted breech delivery]  with forceps to aftercoming head

5.MD.56.PC

Breech delivery with episiotomy, partial breech extraction [assisted breech delivery] with forceps to aftercoming head

5.MD.56.NR

Breech delivery without episiotomy, total breech extraction with forceps to aftercoming head

5.MD.56.PF

Breech delivery with episiotomy, total breech extraction with forceps to aftercoming head

5.MD.56.NW

Breech delivery without episiotomy, unspecified breech extraction with forceps to aftercoming head

5.MD.56.PJ

Breech delivery with episiotomy, unspecified breech extraction with forceps to aftercoming head

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

  1. Newborn abstracts with brain damage due to birth injury (P10.–, P11.1 or P11.2) as diagnosis type (M) or (1) AND preterm and low birth weight

    (P07.–) as diagnosis type (M), (1) or (2) OR
  2. Newborn abstracts with termination of pregnancy affecting fetuses and newborns (P96.4) OR
  3. Newborn abstracts with congenital malformations of the central nervous system (Q00–Q07) as diagnosis type (M) or (1) OR
  4. Newborn abstracts with congenital malformations and deformations of the musculoskeletal system (Q65–Q79) as diagnosis type (M) or (1)

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

P14.-

Birth injury to peripheral nervous system

P15.-

Other birth injuries

Additional Codes

Inclusions

5.MD.53.^^

Forceps traction and rotation delivery

5.MD.54.^^

Vacuum traction delivery

5.MD.55.^^

Combination of vacuum and forceps delivery

5.MD.56.NN

Breech delivery without episiotomy, partial breech extraction [assisted breech delivery] with forceps to aftercoming head

5.MD.56.PC

Breech delivery with episiotomy, partial breech extraction [assisted breech delivery] with forceps to aftercoming head

5.MD.56.NR

Breech delivery without episiotomy, total breech extraction with forceps to aftercoming head

5.MD.56.PF

Breech delivery with episiotomy, total breech extraction with forceps to aftercoming head

5.MD.56.NW

Breech delivery without episiotomy, unspecified breech extraction with forceps to aftercoming head

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.