In simple words: During childbirth, the area between the vagina and anus, called the perineum, can sometimes tear. A second-degree tear means the tear goes through the skin and the muscles underneath but doesn't reach the anus.

A second-degree perineal laceration sustained during delivery, involving the skin and vaginal mucosa, the underlying perineal muscles and fascia.It does not involve the anal sphincter.This condition may occur spontaneously or as an extension of an episiotomy.

Example 1: A woman delivering vaginally experiences a tear that involves the skin, vaginal mucosa, and perineal muscles, but not the anal sphincter. This is diagnosed as a second-degree perineal laceration and is repaired with sutures., An episiotomy is performed during delivery, but the tear extends beyond the incision, involving the perineal muscles. This extension classifies the laceration as second-degree., Following a vaginal delivery, a woman reports pain and bleeding from the perineal area. Examination reveals a second-degree laceration not initially identified, requiring subsequent repair.

Documentation should include a detailed description of the location and extent of the laceration, including the tissues involved. The method of repair and any complications encountered during the repair process should also be documented.

** ICD-10-CM codes from chapter 15 (Pregnancy, childbirth, and the puerperium) are to be used only on the mother's record, not the newborn's.Additional codes may be used to specify weeks of gestation (Z3A) and complications such as postpartum hemorrhage (O72).Excludes1 notes indicate conditions that cannot be coded together (supervision of normal pregnancy, Z34.-), while Excludes2 notes denote conditions that may occur together, but are classified elsewhere (mental disorders, F53.-).