Copyright © 2012 by Mosby, an imprint of Elsevier Inc. PREGNANCY, CHILDBIRTH, AND THE PUERPERIUM Chapter Seven

2 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts gravid/o, -gravida, -cyesis = pregnancy nulli- = none primi- = first multi- = many Anatomy and Physiology of Pregnancy Conception Coitus/copulation Gestation  Gravida  Nulligravida  Primigravida  Multigravida

3 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. CM Guideline Alert 15.a. General Rules for Obstetric Cases  1) Codes from Chapter 15 and sequencing priority  Obstetric cases require codes from Chapter 15, codes in the range O00-09a, Pregnancy, Childbirth, and the Puerperium. Chapter 15 codes have sequencing priority over codes from other chapters. Additional codes from other chapters may be used in conjunction with Chapter 15 codes to further specify conditions. Should the provider document that the pregnancy is incidental to the encounter, then code Z33.1, Pregnant state, incidental, should be used in place of any Chapter 15 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.  2) Chapter 15 Codes used only on the maternal record  Chapter 15 codes are to be used only on the maternal record, never on the record of the newborn.

4 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Time Periods of Pregnancy Normal Length  EDD  LMP Trimesters

5 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. CM Guideline Alert 15.a.3 Final Character for Trimester  The majority of codes in Chapter 15 have a final character indicating the trimester of pregnancy. The timeframes for the trimesters are indicated at the beginning of the chapter. If trimester is not a component of a code it is because the condition always occurs in a specific trimester, or the concept of trimester of pregnancy is not applicable. Certain codes have characters for only certain trimesters because the condition does not occur in all trimesters, but it may occur in more than just one.  Assignment of the final character for trimester should be based on the providers documentation of the trimester (or number of weeks) for the current admission/encounter. This applies to the assignment of trimester for pre-existing conditions as well as those that develop during or are due to the pregnancy. The provider’s documentation of the number of weeks of pregnancy may be used to assign the appropriate code identifying the trimester.  Whenever delivery occurs during the current admission, and there is an “in childbirth” option for the obstetric complication being coded, the “in childbirth” code should be assigned.

6 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts blast/o = embryonic, immature -cyst = sac troph/o = development, nourishment -blast = embryonic, immature Anatomy of Pregnancy Zygote Morula Blastocyst  Implantation  hCG  Trophoblast

7 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts mono- = one chorion/o = chorion, outer fetal sac -ic = pertaining to di- = two amni/o = amnion, outer fetal sac -tic = pertaining to Anatomy of Pregnancy Twins  Monozygotic  Dizygotic  Dichorionic/diamniotic  Monochorionic/diamniotic  Monochorionic/monoamniotic  Conjoined twins

8 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Review Question A woman who is a nulligravida: A. has never been pregnant B. has been pregnant once C. has been pregnant two or more times

9 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts fet/o = fetus post- = after Anatomical Development and Trimesters Zygote  3 weeks Embryo  3-8 weeks Fetus  >8 weeks  Trimester development  Term pregnancy  Post-term  weeks  Prolonged pregnancy  >42 weeks

10 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts extra- = outside chori/o, chorion/o = chorion placent/o = placenta amni/o = amnion umbilic/o, omphal/o = umbilicucs Extraembryonic Membranes Amnion  Amniotic fluid  Allantois  Umbilical cord Chorion  Placenta  Chorionic villi Uterus of a pregnant woman

11 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Signs of Pregnancy

12 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts part/o, -para, -partum = parturition, delivery ante- = before intra- = within nulli- = none primi- = first multi- = many Delivery and Childbirth Parturition  Antepartum  Intrapartum  Postpartum Parity  Nullipara  Primipara  Young  Elderly  Multipara  Grand multiparity Puerperium

13 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. CM Guideline Alert The Peripartum and Postpartum Period 1) Peripartum and postpartum periods The postpartum period begins immediately after delivery and continues for 6 weeks following delivery. The peripartum period is defined as the last month of pregnancy to 5 months postpartum. 2) Peripartum and postpartum complications A postpartum complication is any complication occurring within the 6-week period. 3) pregnancy-related complications after 6-week period Chapter 15 codes may also be used to describe pregnancy –related complications after the peripartum or postpartum period if the provider documents that a condition is pregnancy related.

14 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Review Question The 6-week time period after a delivery is termed: A. parturition B. puerperium C. gestation D. copulation

15 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts -tocia = labor Stages of Labor First  Early/latent  Active  Transitional Second Third

16 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts neo- = new nat/o = birth pre- = before ante- = before peri- = around post- = after Birth Nat/o  Neonate  Prenatal/antenatal  Perinatal  Postnatal

17 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Newborn Weights and Length of Gestation Terminology Extremely low birth weight Extreme immaturity Other immaturity Late newborn, not heavy for gestational age Prolonged gestation Exceptionally large newborn Heavy for gestational age Light for gestational age (LGA) vs. small for gestational age (SMA) Be Careful! LGA is an abbreviation that has in the past meant “large for gestational age” but which now means “light for gestational age.”

18 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. CM Guideline Alert 16.d. Prematurity and Fetal Growth Retardation  Providers utilize different criteria in determining prematurity. A code for prematurity should not be assigned unless it is documented. Assignment of codes in categories P05, Disorders of newborn related to slow fetal growth and fetal malnutrition, and P07, Disorders of newborn related to short gestation and low birth weight, not elsewhere classified, should be based on the recorded birth weight and estimated gestational age. Codes from category P05 should not be assigned with codes from category P07.

19 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. CM Guideline Alert 16.e. Low Birth Weight and Immaturity Status  Codes from category P07, disorders of newborn related to short gestation and low birth weight, not elsewhere classified, are for use for a child or adult who was premature or had a low birth weight as a newborn and this is affecting the patient’s current health status.

20 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Special Note When both birth weight and gestational age of the newborn are available, both should be coded with birth weight sequenced before gestational age.

21 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. APGAR Score A: appearance P: pulse G: grimace A: activity R: respiration

22 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Be Careful! LGA is an abbreviation that has in the past been used to mean “large for gestational age” but which now means “light for gestational age.”

23 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Review Question Birth takes place during which stage of labor? A. First B. Second C. Third D. Fourth

24 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts ec- = out top/o = place -ic = pertaining to hydatid/i = water drop -form = shape Pregnancy with Abortive Outcome (O00-O08) Ectopic pregnancy Hydatidiform mole Miscarriage/abortion  Spontaneous vs. therapeutic  Missed  Incomplete Ectopic pregnancy

25 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. CM Guideline Alert 16.g. Stillbirth  Code P95, Stillbirth, is only for use in institutions that maintain separate records for stillbirths. No other code should be used with P95. code P95 should not be used on the mother’s record.

26 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts -edema = swelling hem/o = blood -lysis = breaking down pre- = before Edema, Proteinuria, and Hypertensive Disorders in Pregnancy, Childbirth, and the Puerperium (O10-O16) Eclampsia in pregnancy Gestational edema HELLP syndrome  Hemolysis, elevated liver enzymes, low platelet count Preeclampsia

27 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts phleb/o = vein -it is = inflammation hyper- = excessive -emesis = vomiting gravidarum = pregnancy prurit/o = itching Other Maternal Disorders Predominately Related to Pregnancy (O20-)29) Gestational phlebitis Hyperemesis gravidarum PUPP  Pruritic urticarial papules and plaques

28 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Review Question Which of the following terms describes a pregnancy that is “out of its (normal) place”? A. HELLP B. PUPP C. eclampsia D. ectopic pregnancy

29 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts cephal/o = head pelv/i = pelvis -ic = pertaining to cervic/o = cervix -al = pertaining to mal- = bad, abnormal The Fetus and Amniotic Cavity and Possible Delivery Problems (O30-O48) Cephalopelvic disproportion Cervical incompetence Malpresentation of fetus

30 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. The Fetus and Amniotic Cavity and Possible Delivery Problems (O30-O48) Abruptio placentae

31 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word parts erythr/o = red (blood cell) blast/o = immature -osis = abnormal condition The Fetus and Amniotic Cavity and Possible Delivery Problems (O30-O48) Twin-to-twin transfusion syndrome (TTTS) Erythroblastosis fetalis

32 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts olig/o = scanty hydr/o = water, fluid -amnios = amnion poly- = excessive chori/o = chorion amnion/o = amnion -itis = inflammation The Fetus and Amniotic Cavity and Possible Delivery Problems (O30-O48) Oligohydramnios Polyhydramnios Chorioamnionitis

33 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts placent/o = placenta -it is = inflammation previa = in front of ac- = toward cret/o = to grow -a = noun ending per- = through in- = in The Fetus and Amniotic Cavity and Possible Delivery Problems (O30-O48) Placentitis Placenta previa Placenta accreta Placenta increta Placenta percreta

34 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts nuch/o = neck -al = pertaining to dys- = abnormal, difficult -tocia = labor, childbirth Complications of Labor and Delivery (O60—O77) Nuchal cord Dystocia  Meconium staining

35 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts a- = without galact/o = milk -ia = condition -rrhea = flow, discharge hypo- = deficient, below puerper/o = puerperium -al = pertaining to sepsis = infection Complications Predominantly Related to the Puerperium (O85-O92) Agalactia Galactorrhea Hypogalactia Puerperal sepsis

36 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. CM Guideline Alert 15.k. Puerperal Sepsis  Code O85, Puerperal sepsis, should be assigned with a secondary code to identify the causal organism (e.g. for a bacterial infection, assign a code from category B95-B97, Bacterial infections in conditions classified elsewhere). A code from category A40, Streptococcal sepsis, or A41, Other sepsis, should not be used for puerperal sepsis. If applicable, use additional codes to identify severe sepsis (R65.2-) and any associated acute organ dysfunction. Needs additional code for causal organism.

37 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts chori/o = chorion -carcinoma = cancer of epithelial origin Malignant Neoplasms (C58) Choriocarcinoma

38 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Review Question Which term describes a condition of deficient amniotic fluid? A. chorioamnionitis B. oligohydramnios C. polyhydramnios D. erythroblastosis fetalis

39 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Prenatal Diagnosis Alpha fetoprotein (AFP) test Contraction stress test (CST) Nonstress test (NST) Pregnancy test

40 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts amni/o = amnion -centesis = surgical puncture chorion/o = chorion pelv/i = pelvis -metry = measuring Prenatal Diagnosis Amniocentesis Chorionic villus sampling (CVS) Pelvimetry Amniocentesis

41 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Pregnancy and Delivery Cerclage

42 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Pregnancy and Delivery Cesarean section (C-section, CS)

43 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Word Parts cephal/o = head -ic = pertaining to version = turning episi/o = vulva -tomy = cutting vagin/o = vagina -al = pertaining to Pregnancy and Delivery Procedures Cephalic version Episiotomy VBAC (vaginal birth after C- section) Vaginal delivery  Presentation  Assistance  PCS: delivery = extraction Episiotomy

44 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. PCS Guideline Alert C1  Procedures performed on products of conception are coded to the Obstetrics section. Procedures performed on the pregnant female other than the products of conception are coded to the appropriate root operation in the Medical and Surgical section.

45 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. PCS Guideline Alert C2  Procedures performed following a delivery or abortion for curettage of the endometrium or evacuation of retained products of conception are all coded in the Obstetrics section, to the root operation Extraction and the body part Products of Conception, Retained. Diagnostic or therapeutic dilation and curettage performed during times other than the postpartum or post-abortion period are all coded in the Medical and Surgical section, to the root operation Extraction and the body part Endometrium.

46 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Suffixes and Root Operations for Pregnancy, Childbirth, and the Puerperium -centesisdrainage (products of conception) -metrymeasurement -tomyrelease, division, drainage

47 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Review Question Which term describes a procedure to turn the head of the fetus towards the cervical outlet for a vaginal delivery? A. CS B. cerclage C. cephalic version D. CVS

48 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Sort these terms into their correct categories Terms 1. chorioamnionitis 2. agalactia 3. cerclage 4. amniocentesis 5. parturition Categories __ A + P __ Pathology __ Procedures