In the 41st week of her first pregnancy, a 37-year-old woman arrived at Labor and Delivery at 6:30 a.m. for a planned induction of labor due to mild, pregnancy-induced hypertension. After i
PATIENT: PETROVICH, CAROLINE
ACCOUNT/EHR #: P018-0546336
DATE: 05/26/18
OB/GYN: Terrence Orkin, Jr., MD
Epidural administered by Yomayra Monterro, MD
In the 41st week of her first pregnancy, a 37-year-old woman arrived at Labor and Delivery at 6:30 a.m. for a planned induction of labor due to mild, pregnancy-induced hypertension.
After intra-vaginal placement of misoprostol, the nurse observed her briefly and, at 11:00 a.m., discharged her from the unit. She went for a walk with her husband in a park next to the hospital.
Patient’s membranes spontaneously ruptured and she returned to the labor and delivery unit. A recently hired, new graduate nurse admitted the patient, took her vital signs, and checked the fetal heart rate. The mother’s blood pressure was 176/95 but the nurse thought this was related to nausea,vomiting, and discomfort from the contractions.
The resident examined the mother, determined that her cervix was 5-6 cm, 90 percent effaced and the vertex was at 0 station. An internal fetal heart monitor was placed because the mother’s vomiting and discomfort caused her to move around too much in the bed, making it hard to record the fetal heart rate with an external monitor. The internal monitor revealed a steady fetal heart rate of 120 and no decelerations.
The mother continued to complain of painful contractions and requested an epidural. Shortly after placement of the epidural, the monitor recorded a prolonged fetal heart rate deceleration. The heart rate returned slowly to the baseline rate of 120 as the nurse repositioned the mother, increased her
intravenous fluids and administered oxygen by mask.
An epidural analgesia infusion pump was started. The fetal heart rate strip indicated another deceleration that recovered to baseline. The nurse informed the resident who checked the tracing and told her to “keep an eye on things.”
The primary nurse noted in the labor record that the baseline fetal heart rate was “unstable, betweenb 100 and 120” but she did not report this to the resident.
The nurse recorded that the fetal heart rate was “flat, no variability.” As the nurse was documenting this as a non-reassuring fetal heart rate pattern, the patient expressed a strong urge to push and the nurse called for an exam.
A resident came to the bedside, examined the mother and noted that she was fully dilated with the caput at +1. A brief update was written in the chart, but the clinician who had performed the exam was not noted.
The mother was repositioned and began pushing.
The fetal heart rate suddenly dropped and remained profoundly bradycardic for 11 minutes. The resident was called and attempted a vacuum delivery, since the fetal head was at +2 station. The attending then entered and attempted forceps delivery.
An emergency cesarean delivery was performed; the baby was stillborn. The physician identified a uterine rupture that required significant blood replacement.
I need help finding thee codes
You’re looking for:
Six ICD-10-CM diagnosis codes
Connect wants O71.1 for the third diagnosis code, but this is incorrect. The documentation states that “Patient’s membranes spontaneously ruptured,” and that means her water broke-a normal part of labor. The O71.1 code is for when the muscular wall of the uterus tears and ruptures. It causes severe bleeding and is life threating to the mother and baby.
One ICD-10-PCS procedure code.
We’ll call this a classical procedure.
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