Chapter R - Female genital tract associated with pregnancy, childbirth and puerperium

Question 1

What type of procedures are excluded from Chapter R?

Answer 1

Operations associated with abortive outcome
(classified to Chapter Q instead)

Question 2

What is the sequencing rule when codes from both categories Y53 or Y68 for method of image control and category Y95 gestational age are required?

Answer 2

The code from Y53/Y68 must be sequenced before Y95.

Question 3

What are the key points and sequencing rules of standard PCHSR1: Coding deliveries?

Answer 3

• The delivery code (R17-R25) must be assigned in a primary position on all delivery episodes
• R24.9 All normal delivery must only be assigned when no other code in R17-R25 applies
• If one type of delivery method is changed for another, only the successful delivery method is coded.

Question 4

If a pregnant patient admitted for an elective caesarean is found to be in labour prior to surgery, how must the caesarean delivery be coded and why?

Answer 4

As an emergency caesarean as all caesareans performed whilst the patient is in labour are to be coded as emergency caesareans (R18.-)

Question 5

How must multiple deliveries be coded?

Answer 5

• Each different type of delivery must be coded, with the most serious being sequenced first
• Where all methods of delivery are the same, only one code is required

Question 6

What does the abbreviation ARM stand for?

Answer 6

Artificial rupture of membranes

Question 7

If multiple forms of medical induction of labour are used, how should this be coded?

Answer 7

R15.1 Medical induction of labour should only be assigned once per consultant episode even if multiple different forms are given.

Question 8

What is the qualifying factor in determining which code to assign from category R21 for forceps delivery?

Answer 8

The type of delivery, i.e. low, mid, high, and not the name of the forceps

Question 9

Explain the standard PCSR6: Gentle cord traction for removal of retained placenta

Answer 9

PCSR6: Gentle cord traction for removal of retained placenta states that gental cord traction performed to remove a retained placenta forms part of the management of ‘normal’ delivery and cannot be classified using OPCS-4 code.
(Not to be confused with R29.1 Manual removal of placenta from delivered uterus which would be coded)

Question 10

What is meant by cephalic presentation?

Answer 10

The fetal head is presenting first in labour (head first)

Question 11

What do the following abbreviations mean in relation to fetal presentation?
* ROP/LOP
* ROT/LOT
* ROA/LOA

Answer 11

• ROP/LOP - Right/Left occipitoposterior
• ROT/LOT - Right/Left occipitotransverse
• ROA/LOA - Right/Left occipitoanterior

Question 12

When must a code for episiotomy be coded and in which sequence?

Answer 12

Must be coded when carried out to facilitate delivery.
Sequenced secondary to the delivery code

Question 13

According to PCSR5: Episiotomy to facilitate delivery and subsequent repair (R27.1, R32), when is it permissible to code the repair of an episiotomy?

Answer 13

Repair is only coded if the episiotomy extends to a perineal tear

Question 14

When must a code for Anti D (X30.1) be assigned?

Answer 14

It must be recorded each time it is given