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 | - 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
- 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
- Newborn abstracts with
termination of pregnancy affecting fetuses and newborns (P96.4) OR
- Newborn abstracts with congenital
malformations of the central nervous system (Q00–Q07) as diagnosis type (M)
or (1) OR
- 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 | - 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 - Newborn abstracts with termination of pregnancy affecting
fetuses and newborns (P96.4) OR
- Newborn abstracts with congenital malformations of the
central nervous system (Q00–Q07) as diagnosis type (M) or (1) OR
- 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.
