In simple words: This code describes a severe tear during childbirth that goes through the vaginal opening, the skin and muscle between the vagina and anus, the muscle that controls the anus, and the lining of the rectum.

Perineal laceration, rupture or tear during delivery as in O70.2, also involving anal mucosa and/or rectal mucosa.

Example 1: A woman giving birth vaginally experiences a tear that extends through the perineal skin, muscles, anal sphincter, and rectal mucosa. This is diagnosed as a fourth-degree perineal laceration and requires surgical repair., A patient who had a previous fourth-degree perineal laceration experiences a recurrence during a subsequent vaginal delivery. The tear is carefully assessed and repaired, considering the patient's history., During a forceps-assisted delivery, a fourth-degree perineal laceration occurs. The obstetrician immediately assesses and repairs the tear to minimize long-term complications.

Documentation should clearly specify the degree of the perineal laceration, the involvement of the anal sphincter and rectal mucosa, and the method of repair. Any associated complications, such as bleeding or infection, should also be documented.