SESI 2
CHAPTER XV
PREGNANCY, CHILBIRTH AND
THE PUERPERIUM
(O00-O99)
BAB XV
DESCRIPTION
Pembahasan materi meliput pengenalan istilah-istilah gangguan Kehamilan, Kelahiran & Masa Nifas, cara menentukan kode diagnosis agar akurat, tepat
TUJUAN INSTRUKSIONAL UMUM
Mampu menentukan kode diagnosis gangguan kehamilan, persalaian dan nifas dengan presisi akurat dan tepat, berhasil mengumpulkan,
TUJUAN INSTRUKSIONAL KHUSUS
Menjelaskan:
- Definisi berbagai gangguan kehamilan, persalaiann dan nifas.
- Kekhususan Bab XV
- Note, excludes, dan includes serta tanda baca lain-lian yang menyertai nomor kode kategori
dan subkategori Bab XV
- kode metode persalinan (bisa untuk menggantikan kode tindakan sistem klasifikasi lain).
- Cara mencari dan memilih kode diagnosis gangguan kehamilan, persalinan dan nifas dengan presisi, akurat dan tepat
BAB XV, KEHAMILAN, KELAHIRAN & MASA NIFAS (O00-O99)
EXCLUDESs (Tidak termasuk ke Bab ini) adalah: • [HIV] diseases (B20-B24)
• Cedera, keracunan & konsekuensi lain akibat sebab luar (S00-T98)
• Gangguan mental & prilaku yang terkait masa nifas (F53.-)
• Tetanus obstetrik (A34)
• Nekrosis postpartum kelenjar pituitari (E23.0) • Osteomalacia postpartum (M83.0)
Bab XV (Lanjutan-1)
Bab ini meliput 8 blok sebagai berikut: (hal. 1-721) O00-O08 Kehamilan dengan abortus
O10-O16 Edema, proteinuira & gangguan hipertensi pada kehamilan, kelahiran & nifas
O20-O29 Gangguan-2 maternal lain yang utamanya terkait kehamilan.
O30-O48 Asuhan maternal terkait janin, kantung ketuban yang kemungkinan menimbulkan masalah persalinan/kelahiran
O60-O75 Komplikasi persalinan dan kelahiran
O80-O84 Kelahiran/Metode persalinan
O85-O92 Komplikasi yang utamanya berkaitan dengan masa nifas
Kehamilan dengan hasil Abortus
(O00-O08)
EXCLUDES: kehamilan berlanjut setelah satu atau lebih dari satu janin gugur pada suatu kehamilan multipel.
Perhatikan:
O00 Kehamilan di luar kandungan
Includes: …
Use additional code dari …O08.-O01 Mola hidatidiform
Use additional code dari … O08.-O02.- Produk konsepsi abnormal lain-lian
Use additional code dari … O08.-
Excludes: …
Kehamilan dengan hasil Abortus (O00-O08) (Lanjutan-1)
Perhatikan:
• Penjelasan di bagian atas halaman 724 Volume 1: Ada tersedia subdivisi dengan tambahan code karakter ke-4 untuk melengkapi O03-O06
• Adanya:
[See above for subdivisions] atau [See page 724 for subdivisions]
yang ada pada masing-masing code terkait.
Kehamilan dengan hasil Abortus
(O00-O08) (Lanjutan-2)
O08 Complicating following abortion & ectopic & molar pregnancy
Note: This code is provided primary for morbidity coding. For use of this category reference sholud be made to the morbidity coding rules & quidlines in Volume 2.
O10-O16 meliput gangguan edema, proteinuria & gangguan hipertensi pada kehamilan, perslianan & nifas.
Includes: the listed conditions with pre-existing proteinuria
Kehamilan dengan hasil Abortus (O00-O08) (Lanjutan-3)
Perhatikan penjelasan pada masing-masing code
O15 Eclampsia
Ada koreksi dengan tambahan:
- eclampsia with pregnancy –induced or pre-existing hypertension.
(Lihat corrigenda di buku Vol. 3)
Other maternal disorders predominantly
related to pregnancy
(O20-O29)
Note: Categories O24.- and O25 include the listed
conditions even if they occure during childbirth or the puerperium.
Excludes: maternal:
• care related to the fetus and amniotic cavity & possible delivery problems (O30-O48)
Other maternal disorders predominantly
related to pregnancy
(O20-O29)
Perhatikan definisi untuk:
O20 Haemorrhage in early pregnancy
Excludes: …
Perhatikan definisi pada:
O21 Excessive vomiting in pregnancy
O22 Venous complications in pregnancy
Excludes: …
Other maternal disorders predominantly related to pregnancy
(O20-O29) (Lanjutan)
Perhatikan Excludes yang menyertai masing kategori.
O28 Abnormal findings on antenatal screening of mother
Excludes:
Diagnostic findingd classified elsewhere – see Alphabetical Index.
Maternal care related to the fetus & amniotic cavity & possible delivery problems
Other maternal disorders predominantly related to pregnancy (O20-O29)
O29 Complication of anaesthesia during pregnancy
Includes: … Excludes:
Maternal care related to the fetus & amniotic cavity & possible delivery problems (O30-O48)
Complications of Labour & Delivery
(O60-O75)
O60 Preterm delivery
Perhatikan definisi untuk ini (hal 1-744)
O63 Long labour
Perhatikan hubungan long labour dengan kala persalinan.
O64 Obstructed labour due to malposition & malpresentation of fetus (sebab adalah letak/presentasi janin)
O65 Obstructed …
Complications of Labour & Delivery (O60-O75) (Lanjutan-1)
O66 Other obstructed …
O67 Persalinan & kelahiran terkomplikasi perdarahan intrapartum, yang tidak
terklasifikasi di tempat lain.
O68 - idem - terkomplikasi oleh fetal stress [distress]
O69 - idem – complicated by umbilical cord complications
O70 Perineal laceration during delivery
(Luka lecet/gores pada perineum saat proses kelahiran)
Includes: episiotomy extended by laceration
Complications of Labour & Delivery (O60-O75) (Lanjutan-2)
O71 Other obstetric trauma
Includes: damage from instruments.
O72 Postpartum haemorrhage
Includes: haemorrhage after …
O73 Retained placenta & membranes, without haemorrhage.
O74 Complications of anaesthesia during labour & delivery
Includes: …
O75 Other complications of labour & delivery, not elsewhere
classified.
DELIVERY
(PERSALINAN)
(O80-O84)
Note: Kode O80-O84 tersedia untuk kepentingan code morbiditas.
Kode-2 di blok ini hendaknya digunakan untuk kode primer morbiditas hanya apabila tidak ada
kondisi lain yang terklasifikasi di bab XV ter- rekam. Bila kategori-2 ini akan digunakan, rujuklah ke peraturan Morbidity Coding Rukes di Volume 2.
O80 Single spontaneous delivery
O81 Single delivery by forceps & vacuum extractor O82 Single delivery by caesarean section
DELIVERY (PERSALINAN) (Lanjutan)
O84 Multiple delivery
Use additional code (O80-O83), if disired,
to indicate the method of delivery of each fetus (janin) or infant (bayi)
Complications predominantly related to the
puerperium (O86-O92)
Komplikasi yang utamanya terkait masa nifas:
Note: Categories O88.-, O91.-,O92.- include the listed conditions even if they occur during pregnancy and childbirth.
Excludes: mental & behavioural disorders associated with the:
puerperium (F53.-)
ostetrical tetanus (A34)
Complications predominantly related to the puerperium (O86-O92) (Lanjutan-1)
O85 Puerperal sepsis
Puerperal endometritis, fever, peritonitis, septicaemia.
Use additional code (B95-B97), if desired, to identify infection agent.
Excludes: …
O86 Other puerperal infection
Complications predominantly related to the puerperium (O86-O92) (Lanjutan-2)
O87 Venous complications in the puerperium
Includes: in labour, delivery, and the puerperium.
Excludes: obstetric embolism (O88.-)
venous complications in pregnancy (O22.-)
O88 Obstetric embolism
Includes: pulmonary emboli in pregnancy, childbirth or the puerperium
Complications predominantly related to the puerperium (O86-O92) (Lanjutan-3)
O89 Complication of anesthesia during the puerperium
Includes: maternal complications arising from the administration of general or local anaesthetic, analgesic or other
sedation during the puerperium.
O90 Complications of the puerperium, NEC
O91 Infections of breast associated with childbirth
Includes: …
O92 Other disorders of breast and lactation associated with childbirth.
Other obstetric conditions, NEC
(O95-O99)
Note: For use of categories O95-O97 reference should be made to the mortality coding rules and
guidelines in Volume 2
O95 Obstetric death of unspecified cause
Maternal death from unspecified cause occurring during pregnancy, labout and delivery, or the
puerperium.
O96 Death from any obstetric cause occurring > than 42 days but < than one year after delivery.
Other obstetric conditions, NEC (O95-O99) (Lanjutan-1)
O97 Death from sequelae of direct obstetric causes. Death from any direct obstetric cause occurring one year or more after delivery.
O98 Maternal Infectious & parasitic diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium
Includes: …
Use additional code (Chapter I) if desired, to identify specific condition.
Other obstetric conditions, NEC (O95-O99) (Lanjutan-2)
O99 Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium.
Note: This categories includes conditions which complicate the pregnancy state, are
aggravated by pregnancy or are a main reason for obstetric care and for which the Alphabetical Index does not indicate a specific rubric in Chapter XV.
Other obstetric conditions, NEC (O95-O99) (Lanjutan-3)
Excludes:
Infectious and parasitic diseases (O98.-) Injury, poisoning and certain other
consequences of external causes (S00-T98) When the reason for maternal care is that the condition is known or suspected to have affected the fetus (O35-O36)
LATIHAN PENYELESAIAN SOAL-SOAL
SOAL LATIHAN MANDIRI
1. Partus seksio No: Kembar dempet terhubung di abdomen No: Berat badan kedua bayi di atas 2.250 kg. No: Cengeng sulit menete ASI No: 2. Persalinan macet No: Myoma uteri No: Lahir Vakum No: Bayi cephalohematom No: 3. Partus spontan, cukup bulan, bayi sehat No: No: No: 4. Persalinan induksi gagal dengan suntikan oxytocin No:
