Question

101.     Select the most correct maternal codes for the following clinical scenario:

Assessment

1. 37 week, 5 day intrauterine pregnancy

2. Non-reassuring fetal heart tones

3. Patient is dilated to 4 and 80% effaced.

Plan

Labor induction via Pitocin drip

Procedures

Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal wall laceration

Repair of third-degree midline laceration

Anesthesia: Local

Blood loss: 300 mL

Complications: None

Findings

1. Live male infant with Apgars of 9 and 9

2. Placenta delivered spontaneously, intact, 3 vessels

Disposition: Patient and baby remain the LDR in stable condition

Summary: This is a 31-year-old G1 woman who was 37 weeks, 5 days pregnant admitted for induction for nonreassuring heart tone. She had no regular contractions. Fetal heart tones were nonreassuring with variable decelerations. She was started on Pitocin for labor induction and labored rapidly with spontaneous rupture of membranes and clear fluid. There was no time for administration of an epidural. During pushing, the decelerations did not recover between contractions. Therefore, vacuum extraction was initiated. The vacuum was placed and the correct placement in front of the posterior fontanelle was confirmed digitally. With the patient’s next contraction, the vacuum was inflated and a gentle downward pressure was used to assist with brining the baby’s head to a +3 station. The contraction ended. The vacuum was released and the fetal heart tones remained in the, at this time, 90s to 100s. With the patient’s next contraction, the vacuum was reapplied and the baby’s head was delivered to a +4 station. A modified Ritgen maneuver was used to stabilize the fetal head. The vacuum was deflated and removed. The baby's head then delivered atraumatically. There was no nuchal cord. The baby’s anterior shoulder delivered after a less than 30-second delay. No additional maneuvers were required to deliver the anterior shoulder. The posterior shoulder and remainder of the body delivered easily. The baby’s mouth and nose were bulb suctioned. The cord was clamped x2 and cut. The infant was handed to the respiratory therapist.

Pitocin was added to the patient's IV fluids. The placenta delivered spontaneously, was intact and had a three-vessel cord. A vaginal inspection revealed a third-degree midline laceration as well as a right vaginal side wall laceration. The right-side wall laceration was repaired with #3-0 Vicryl suture in a running fashion with local anesthesia. The third-degree laceration was also repaired with #3-0 Vicryl sutures. Local anesthesia was used. The capsule was visible but did not appear to be injured at all. It was reinforced with three separate interrupted sutures and then the remainder of the incision was closed with #3-0 Vicryl in the typical fashion.

The patient tolerated the procedure very well. She remains in the LDR with the baby. The baby is vigorous, crying and moving all extremities. He will go to the new born nursery when ready. The total time for repair of the laceration was 25 minutes.

1. O76, O70.20, O62.3, Z37.0, Z3A.37
2. O76, O70.20, Z37.0, Z3A.37
3. O80, O76, O70.20, Z37.0, Z3A.37
4. O76, O70.20, O62.3, Z38.0, Z3A.37

Answer 1

​​​​Answer: The correct answer is option D (O76, O70.20, O62.3, Z38.0, Z3A.37) since the codes for this option are in accordance with the sequence flow how what had happened with the patient and how the delivery was conducted.

To begin with;

1. The patient was admitted to the hospital for induction for nonreassuring heart tone so we have the patient coded to O76 which is - O76. Abnormality in fetal heart rate and rhythm complicating labor and delivery.
2. The patient has acquired a third degree perineal laceration during delivery which would be coded to O70.20 for Third degree perineal laceration during delivery
3. The patient was administered with Pitocin for labour induction and this would be coded to O62.3 which is for precipitating labour.
4. The patient delivered a single liveborn infant in the hosptial and this would be coded to Z38.0.
5. Since the patient has carried the child for 37 weeks and the delivery was conducted in the 37th week, this would be coded to Z3A.37 for 37 weeks gestation of pregnancy