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Department of Health

Final specifications for revisions to the Victorian Perinatal Data Collection for 1 July 2015December 2014

Version 1.0

Final specifications for revisions to the Victorian Perinatal Data Collection for 1 July 2015December 2014

Download from the Department of Health web site at:http://www.health.vic.gov.au/ccopmm/vpdc/index.htm

Published By: The Department of Health, Victoria

Authorised By:

The Victorian Government

50 Lonsdale Street, Melbourne

Version: 1.0

http://www.health.vic.gov.au/ccopmm/vpdc/index.htm

Contents

Executive Summary 1

Introduction 2Distribution and contents of this document 2

Orientation to this document 3

Section 1 Introduction 3

Section 2 Concept and derived item definitions 3

Section 3 Data definitions 3

Section 4 Business rules 3

Section 5 Compilation and submission 3Acronyms used in this document 4

Outcome of proposals 5

Testing and implementation 7Method for reporting data after 1 July 2015 7

Test transmissions 7

Specifications for changes from 1 July 2015 8

Section one: Introduction 9Foreword 9

Overview of the VPDC 10

VPDC update cycle 11

Section two: Concepts and derived data items 12

New items 12Anaesthesia 12

Analgesia 12

Antenatal care visit 12

Geographic indicator 13

Gestational diabetes mellitus 13

Hospital in the home (HITH) 14

Hypertensive disorder during pregnancy 14

Primary postpartum haemorrhage 15

Registered nurse 15

Modification to existing items 16Live birth 16

Separation 16

Stillbirth (foetal death) 17

Section three: Data definitions 18

New items 18Influenza vaccination status 18

Number of antenatal care visits 19

Pertussis (whooping cough) vaccination status 21

Modification to existing items 22Anaesthesia for operative delivery – type 23

Analgesia for labour – type 24

Birth plurality 26

Birth status 27

Birth weight 28

Congenital anomalies – free text 29

Congenital anomalies – indicator 30

Country of birth 31

Events of labour and birth – ICD-10-AM code 32

First given name – paediatrician 33

Hospital code (agency identifier) 34

Indication for induction – ICD-10-AM code 35

Indications for operative delivery – ICD-10-AM code 36

Labour type 37

Last birth – caesarean section indicator 38

Maternal medical conditions – ICD-10-AM code 39

Maternal smoking at less than 20 weeks 40

Maternal smoking at more than or equal to 20 weeks 41

Method of birth 42

Neonatal morbidity – ICD-10-AM code 44

Obstetric complications – ICD-10-AM code 45

Parity 46

Perineal/genital laceration – degree / type 47

Postpartum complications – ICD-10-AM code 48

Procedure – ACHI code 49

Residential locality 50

Residential postcode 51

Residential road suffix code – mother 52

Residential road type – mother 53

Separation status – baby 54

Separation status – mother 55

Setting of birth – actual 56

Setting of birth – intended 57

Surname / family name – paediatrician 58

Transfer destination – baby 59

Transfer destination – mother 60

Version identifier 61

Section four: Business rules 62

New items 62Admission to special care nursery (SCN) / neonatal intensive care unit (NICU) – baby, Setting of birth – actual and Hospital code (agency identifier) valid combinations 62

Discipline of antenatal care provider and Number of antenatal care visits valid combinations 65

Fetal monitoring in labour and Labour Type valid combinations 65

Gestational age at first antenatal visit and Number of antenatal care visits valid combinations 65

Modification to existing items 66Anaesthesia for operative delivery – indicator and Method of birth valid combinations 66

Congenital anomalies – indicator and Congenital anomalies – free text conditionally mandatory data item 66

Mandatory to report data items 67

Separation status – baby and Transfer destination – baby conditionally mandatory data item 70

Separation status – mother and Transfer destination – mother – conditionally mandatory data item 70

Discontinued items 71Anaesthesia for operative delivery – indicator and Anaesthesia for operative delivery – type valid combinations 71

Analgesia for labour – indicator and Analgesia for labour – type valid combinations 72

Discipline of lead intrapartum care provider and Setting of birth - actual valid combinations 73

Method of birth ‘Other operative delivery’ and associated data items valid combinations 73

Section five: Submission and compilation 75Episode records 75

File Structure Specifications 81

Header record 81

Data submission timelines 82

Executive Summary

Each year the Department of Health reviews the data items and format of the Victorian Perinatal Data Collection (VPDC) on behalf of the Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM). This review seeks to ensure that the perinatal data collection supports the CCOPMMs and department’s state and national reporting obligations, assists planning and policy development, and incorporates appropriate feedback from data providers on improvements.

The Deputy Secretary, Health Service Performance and Programs, has considered the submitted proposals and based on the recommendations of the CCOPMM, has approved the following revisions to VPDC for reporting births from 1 July 2015.

Key changes are summarised below:

• Introduction of new data item ‘Number of antenatal care visits’ and associated information to inform a National Indigenous Report Agreement performance indicator:– Addition of concept– Addition of data item– Addition of business rules

• Introduction of new data items ‘Influenza vaccination status’ and ‘Pertussis (whooping cough) vaccination status’ – Addition of data items– Modification of business rule

• Introduction and amendments to concepts and data item reporting guides to align with the National Health Data Dictionary:– Addition of concepts– Modification of concepts– Modification of data items

• Amendment to large value domain codesets to facilitate the ongoing accurate reporting of data:– Modification data items

• Introduction of new business rules to improve administrative reporting of special care nursery and neonatal intensive care admissions:– Addition of business rules

• Amendment to compilation and submission guidelines to facilitate reporting of revised specifications:– Modification manual section one ‘Introduction’ and section five ‘Submission and compilation’

• Discontinuation of business rules to facilitate reporting of valid and possible combinations of analgesia and anaesthesia administered in labour and operative deliveries respectively:– Discontinuation of business rules

Final specifications for revisions to the VPDC for 1 July 2015 Page 1

Introduction

The Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) was established in 1962 under the Health Act 1958 to provide advice to the Minister for Health on issues relating to perinatal, maternal and paediatric morbidity and mortality. The Health Act was repealed on 1 January 2010 and replaced by the Public Health and Wellbeing Act 2008 (the Act).

Under the Act, CCOPMM has statutory responsibility for the administration of the Victorian Perinatal Data Collection (VPDC), which is a population based surveillance system to collect and analyse information on, and in relation to, the health of mothers and babies in order to contribute to improvements in their health.

Data is collected via a birth report and contains information on obstetric conditions, procedures and outcomes, neonatal morbidity and birth defects relating to every birth in Victoria of at least 20 weeks gestation (or if gestation is unknown, at least 400 grams birth weight).

The Proposals for Revisions to the Victorian Perinatal Data Collection for births from 1 July 2015 (the Proposal for revisions document) was disseminated in May 2013 to stimulate discussion and invite comment on several proposals to modify the VPDC. Comments provided by health services and software vendors in response to this document have been considered, and where possible, suggestions have been accommodated, resulting in changes to or withdrawal of some proposals.

It is anticipated that future revisions to the collection, where necessary, will be implemented at the beginning of the financial year to align with national reporting obligations and other departmental data collections such as the Victorian Admitted Episode Dataset (admitted patients), the Victorian Emergency Minimum Dataset, Elective Surgery Information System (waiting list patients), and the Victorian Integrated Non-Admitted Health Minimum Dataset (non-admitted patients).

The changes set out in this document are complete as at the date of publication; however, where further changes are required during the year these will be advised via the Perinatal Bulletin available at the website http://www.health.vic.gov.au/ccopmm/vpdc/index.htm.

Distribution and contents of this document

This document has been posted on the department’s website and distributed to all Victorian health services known to have maternity services, to patient and clinical management system software vendors known to have Victorian clients, and other relevant industry bodies .It is accessible at: http://www.health.vic.gov.au/ccopmm/vpdc/index.htm

An updated VPDC Manual will be made available at the same website in due course. The existing manual is available at: http://www.health.vic.gov.au/ccopmm/vpdc/index.htm and subsequent VPDC Bulletins, together with this document, will form the perinatal data transmission specifications for reporting births from 1 July 2015.

Victorian health services are required to arrange for their software to be modified in accordance with the revised specifications and to ensure reporting capability is achieved in order to maintain compliance with the Act.

Any questions related to this document may be directed to the perinatal help desk on 1300 858 505 or [email protected].


mailto:[email protected]




Orientation to this document

This document provides final specifications for revisions to the VPDC Manual (version 3.0) available on the department’s website: http://www.health.vic.gov.au/ccopmm/vpdc/index.htm. The VPDC manual is divided into five sections. A broad overview of each section is provided below.

Section 1 IntroductionProvides an overview of the VPDC and its function, the uses of data collected, contact details, useful references and publications, and a list of acronyms used in this manual.

Section 2 Concept and derived item definitionsProvides definitions of concepts and derived items that contribute to the VPDC.

Section 3 Data definitionsPresents the specifications of data items collected through the VPDC. The data items are arranged in alphabetical order.

For hospitals with an electronic system, this manual describes the data as it should be submitted to the VPDC. The hospital’s software does not need to exactly replicate the VPDC system in all respects; however data must be formatted as specified for the VPDC.

Section 4 Business rules Details the business rules that apply to reporting VPDC data. Tabular business rules provide a quick reference to edits relating to multiple data items.

Section 5 Compilation and submissionProvides the specifications for compiling a VPDC submission, including summary statistics and technical specifications.

Features of this document to highlight the proposals include:

Changes to existing items are highlighted in green Redundant values and definitions relating to existing items are struck through Comments relating only to the proposal document [appear in square brackets and italics].



Acronyms used in this document

ACHI Australian classification of hospital interventions

ARIA Accessibility/remoteness index of Australia

ARM artificial rupture of membranes

CCOPMM Consultative Council on Obstetric and Paediatric Mortality and Morbidity

CSE combined spinal-epidural

DH Department of Health

GBS+ group B streptococcus positive

GDM gestational diabetes mellitus

HDU high dependency unit

HITH hospital in the home

ICD-10-AM international statistical classification of diseases and health related problems, 10th revision, Australian modification

ICU intensive care unit

ml millilitres

NHDD National health data dictionary

NICU neonatal intensive care unit

NPESU National Perinatal Epidemiology and Statistics Unit

RRMA Rural, remote and metropolitan area classification

SCN special care nursery

SDE secure data exchange

SOMANZ Society of obstetric medicine in Australia and New Zealand

TENS transcutaneous electrical nerve stimulation

TER time to establish respiration

Vic Victoria

VPDC Victorian perinatal data collection


Outcome of proposals

Each proposal is assessed against a set of principles, outlined in the Proposals for revision document, designed to assess the impact that implementation of the proposal is likely to have on health services, the department, software vendors and data users. The principles reflect best practice and standard information management principles.

Proposal 1 – Number of antenatal care visits

This proposal will be implemented as it is required for National Minimum Dataset reporting and to measure the ‘PI 09-Antenatal care’ performance indicator under the National Indigenous Reform Agreement (METeOR identifier: 423828).

Positive feedback was received in relation to the importance of measurement and tracking of primary care needs of all Australians and to ensure these are met effectively through timely and quality care in the community. Negative feedback was received in relation to the data accuracy, collection burden and value of this item..

Proposal 2 – Influenza immunisation status during pregnancy

This proposal will be implemented to monitor changes in coverage rates over time and determine the effectiveness of strategies to promote uptake of the influenza vaccine in pregnancy. Positive feedback was received in relation to this proposal.

The proposal was to collect data on mothers who received the influenza vaccination prior to or during the current pregnancy. Following consultation with stakeholders this item has been simplified to determine the women’s immunisation status during the current pregnancy only.

Proposal 3 – Pertussis immunisation status

This proposal will be implemented to monitor changes in coverage rates over time and determine the effectiveness of strategies to promote uptake of the pertussis vaccine in pregnancy. Neither positive nor negative feedback was received in relation to this proposal, however minor revisions to the scope and codeset descriptors were suggested to support the collection and interpretation of meaningful data.


http://meteor.aihw.gov.au/content/index.phtml/itemId/423828

Proposal 4 – Separation status and dates

This proposal will be partially implemented.

Code ‘4 - Transferred and died’ will be removed from data items ‘Separation status - baby’ and ‘Separation status - mother’. Health services are to report the separation status relevant to the birth admission / episode of care. Deaths that occur outside the birth admission will be identified through neonatal and infant death data collected by the CCOPMM.

Code ‘5 Infant death’ will be removed from data item ‘Separation status - baby’. Infant death can be derived from ‘Separation status - baby’, ‘Date of birth - baby’ and ‘Separation date - baby’.

No feedback was received in relation to the two revisions for implementations above.

The proposal to report ‘Separation date - baby’ and ‘Separation date - mother’ greater than 28 days after Date of birth - baby as code ‘77777777’ instead of a valid calendar date will not be implemented. Health services are reminded that data should be submitted within 30 days from ‘Date of birth - baby’.

For episodes of care greater than 28 days, health services should submit available data prior to 30 days after ‘Date of birth - baby’, with ‘Separation date - mother’ and / or ‘Separation date - baby’ reported as supplementary value ‘99999999 - Not stated / inadequately described’. A subsequent record must be sent after mother and / or baby has separated to remediate any VPDC business rules not met.

Feedback in regards to the above two revision implemented was received indicated the cost of state wide implementation would exceed the benefit to health services with birth admissions greater than 30 days.

Proposal 5 – Codeset updates

This proposal will be implemented to ensure data integrity. No comments were received for this proposal.

Proposal 6 – Mechanical induction of labour

This proposal has been deferred pending further development by national data development committees. This proposal was developed in accordance with national data development projects which have since been deferred. No feedback was received for this proposal.

Proposal 7 – Business rule updates

This proposal will be partially implemented to ensure data integrity. Address data validations have been deferred and are pending further consideration in response to feedback from health services and software vendors.

Proposal 9 – Version identifier

This proposal will be implemented to ensure data integrity and facilitate all revisions to the collection. No feedback was received for this proposal.

Proposal 10 – VPDC update cycle

This proposal will be implemented to clarify development of the data collection and revisions process. No feedback was received for this proposal.

Proposal 11 – Discontinuation of optional alternative code

This proposal will be implemented to consolidate and standardise specifications with national standards and specifications implemented in other department data collections. No feedback was received for this proposal.

Proposal 12 – Data submission deadlines

This proposal will be implemented to clarify reporting requirements. No feedback was received for this proposal.


Testing and implementation

Method for reporting data after 1 July 2015

The following data rules apply for VPDC data submissions before and after 1 July 2015:

• ‘Date of birth - baby’ determines the specifications for how a record is to be submitted irrespective of the patient’s separation date or date of data submission. The value of the ‘Version identifier’ contained within the data submission header and episode records identifies the specification for how the data submission was compiled– Births prior to 1 July 2015 must be reported as per current specifications as outlined in the VPDC

Manual version 3.0 with the ‘Version identifier’ identified as ‘2009’ in the header and episode records.

– Births on or after 1 July 2015 must be reported as per the new specifications outlined in the VPDC Manual version 4.0 and incorporating revisions outlined in this document with the ‘Version identifier’ identified as ‘2015’ in the header and episode records.

• Data submission must only contain records pertaining to one specification. For example, to submit records pertaining to births between 1 June 2015 and 31 July 2015, two data submission files must be compiled.

An updated VPDC Manual (version 4.0) will be made available at http://www.health.vic.gov.au/ccopmm/vpdc/index.htm in due course. Until then, the existing VPDC Manual and any subsequent VPDC Bulletins, together with this document, will form the perinatal data transmission specifications for 1 July 2015.

Test transmissions

The Department of Health recognises that software suppliers can experience difficulties making the 1 July revisions to their programs and that distributing untested programs to clients is unsatisfactory. It can also be difficult for hospitals to resolve problems caused by using untested software. The department will therefore be making a test facility available to software suppliers and encourages all suppliers to test new programs before using them to send live data to the VPDC.

After making the necessary programming changes to meet the revised requirements, each software supplier can send test submissions, without charge. The test file must have ‘_TEST’ appended to the file name, for example ‘VPDC_1234_201507010001_01_TEST.txt’. Please contact the perinatal helpdesk ([email protected]) before transmitting a test file to ensure the file is processed appropriately and the test system is configured to receive your file.

Control reports produced for each test will be sent to the health service via the HealthCollect portal in the usual production format, with ‘_TEST’ appended to the file name, for example ‘VPDC_1234_201507010001_01_TEST Clinicians Report.pdf’

Staff at the department will, if requested, assist in identifying problems. However, there is no approval process for testing 1 July updates. Once the software vendor and/or the health service are satisfied that the new software meets the specifications as defined by the department, live transmissions can commence.


mailto:[email protected]


Specifications for changes from 1 July 2015


Section one: Introduction

Foreword

The Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) was established in 1962 under the Health Act 1958 (Vic) as the advisory body to the Minister of Health on maternal, perinatal and paediatric deaths. The Health Act was repealed on 1 January 2010 and replaced by the Public Health and Wellbeing Act 2008.

The functions of CCOPMM are outlined in s. 46 of the Public Health and Wellbeing Act and include the establishment of a perinatal data collection. The Victorian Perinatal Data Collection (VPDC) was established in 1982 as a population-based surveillance system. The purpose of this collection is to enable analysis of information about the health of mothers and babies to contribute to improvements in their health.

Data collected includes information on obstetric conditions, procedures and outcomes, neonatal morbidity and birth defects relating to every birth in Victoria of at least 20 weeks’ gestation or if gestation is unknown, at least 400 grams birth weight.

Data are collected and include information on obstetric conditions, procedures and outcomes, neonatal morbidity and birth defects relating to births in Victoria. The scope of which includes:

Live births: the complete expulsion or extraction from the mother, of a baby, irrespective of the duration of the pregnancy which, after such separation, breathes or shows any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of the voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached.

Stillbirth (occurring before or during labour): a foetal death prior to the complete expulsion or extraction from its mother of a product of conception of at least 20 completed weeks of gestation or at least 400 grams if gestation is unknown. The death is indicated by the fact that after such separation the foetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles.

Information provided to the CCOPMM via the VPDC is privileged from access by any third party, including the courts. However, CCOPMM may, if it determines that it is in the public interest to do so, provide information to bodies specified in s. 41 of the Public Health and Wellbeing Act.

The VPDC is used to populate the National Perinatal Minimum Dataset, but it also contains additional items to enable more detailed analysis on the health of mothers and babies in Victoria. All states and territories must comply with the minimum dataset and submit their data to the National Perinatal Epidemiology and Statistics Unit (NPESU). CCOPMM provides the data for the NPESU under s. 41 of the Public Health and Wellbeing Act.

Data is collected from hospitals, birth centres or homebirth practitioners either via a computerised hospital system or via the birth report form. Electronic data is submitted to the VPDC via a secure data exchange (SDE) portal.

This manual provides comprehensive information for hospitals and agencies on the VPDC, including data definitions and reporting requirements for all service types. The manual will be made available on the department’s website: http://www.health.vic.gov.au/ccopmm/vpdc/index.htm



Overview of the VPDC

The VPDC was established in 1982, by an amendment to the Health Act under the functions of the CCOPMM. The CCOPMM is the advisory body to the Minister of Health on maternal, perinatal and paediatric deaths.

The collection was established as a population-based surveillance system to collect and analyse information on, and in relation to, the health of mothers and babies in order to contribute to improvements in their health. The VPDC contains information on obstetric conditions, procedures and outcomes, neonatal morbidity and birth defects relating to every birth in Victoria of at least 20 weeks’ gestation, or, if gestation is unknown, at least 400 grams birth weight.

Data are collected and include information on obstetric conditions, procedures and outcomes, neonatal morbidity and birth defects relating to births in Victoria. The scope of which includes:

Live births: the complete expulsion or extraction from the mother, of a baby, irrespective of the duration of the pregnancy which, after such separation, breathes or shows any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of the voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached.

Stillbirth (occurring before or during labour): a foetal death prior to the complete expulsion or extraction from its mother of a product of conception of at least 20 completed weeks of gestation or at least 400 grams if gestation is unknown. The death is indicated by the fact that after such separation the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles.

The majority of data items, of which there are nearly 140, comply with the National Perinatal Minimum Data Set, which are collected by all states and territories (all other states have a similar collection to the VPDC), and are sent to the National Perinatal Statistics Unit for the production of the annual report on Australia's mothers and babies.

The VPDC is responsible to the CCOPMM, which also reviews all perinatal, maternal and child (less than 18 years old) deaths. Information provided to the CCOPMM is privileged from access by any third party, including the courts.

However, CCOPMM may, if it determines that it is in the public interest to do so, provide information to bodies specified in s. 41 of the Public Health and Wellbeing Act.


VPDC update cycle

The VPDC is a legislated data collection; as such, only CCOPMM has the legal statutory authority to make changes to the items collected. In the first four months of each calendar year, the Clinical Councils Unit on behalf of CCOPMM, calls for submissions for revisions to the VPDC to take effect from the following 1 July. CCOPMM may elect to make changes to the VPDC to provide data for a change in reporting requirements to the NPESU, to monitor a new policy or research areas of interest, or to follow changes to the National health data dictionary. External submissions received are provided to CCOPMM for consideration. Only those approved by CCOPMM proceed to implementation.

Implementation

Once submissions have been approved by CCOPMM they are outlined in a ‘proposals for revisions’ document, which is circulated to hospitals/agencies, software suppliers and others. All parties have the opportunity to submit comments and questions on the proposals. A forum may then be held to present the proposals in detail. Following this, a ‘specifications for revisions’ document is prepared providing full details of the changes.

Software suppliers should then revise software to be ready to use from 1 January. Hospitals/agencies that do not collect this information electronically will be provided with updated paper forms to reflect any changes. Hospitals/agencies will need to train staff in any changes to the VPDC.

The Proposal for Revisions document is circulated prior to 1 July and interested parties have the opportunity to comment or question the proposals. Following this, the Specifications for Revisions document is released providing full specifications of changes to the data collection.

Health services and reporting agents are responsible for implementing changes in accordance with the Specifications for Revisions and the VPDC Manual.

Health services and reporting agents unable to meet revisions by the implementation date are required to contact the department immediately with the anticipated implementation date. The department will negotiate interim reporting requirements with health services and reporting agents on a case by case basis.

Updates to reference data, such as updates to postcode/locality reference, may occur throughout the year to enable hospitals/agencies to submit accurate data. These updates will be published by the department.


Section two: Concepts and derived data items

New items

Anaesthesia

Definition A technique used to introduce an agent to produce a state of reduced or absence of sensation to the woman for the operative or instrumental delivery of the baby

Analgesia

Definition An analgesic agent or technique administered to the woman to relieve the pain of labour without causing loss of consciousness

Antenatal care visit

Definition An intentional encounter between a pregnant woman and a midwife or doctor to assess and improve maternal and fetal well-being throughout pregnancy and prior to labour

Guide for use An antenatal care visit may occur in the following clinical settings:

antenatal outpatients clinic specialist outpatient clinic general practitioner surgery obstetrician private room community health centre rural and remote health clinic independent midwife practice setting including home of

pregnant female


Geographic indicator

Definition A classification scheme that divides an area into mutually exclusive sub-areas based on geographic location. Some geographic indicators are:

A classification scheme that divides an area into mutually exclusive sub-areas based on geographic location. Some geographic indicators are:

Australian Standard Geographical Classification (ASGC, ABS cat. no. 1216.0, effective up until 1 July 2011)

Australian Statistical Geography Standard (ASGS, ABS cat. nos. 1270.0.55.001 to 1270.0.55.005, effective from 1 July 2011)

Administrative regions Electorates Accessibility/Remoteness Index of Australia (ARIA) Rural, Remote and Metropolitan Area Classification

(RRMA) Country

Context To enable the analysis of data on a geographical basis. Facilitates analysis of service provision in relation to demographic and other characteristics of the population of a geographic area

Gestational diabetes mellitus

Definition Gestational diabetes mellitus (GDM) is a carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy. The definition applies irrespective of whether or not insulin is used for treatment or the condition persists after pregnancy


Hospital in the home (HITH)

Definition Hospital in the home (HITH) services provide care in the home that would otherwise need to be delivered within a hospital as an admitted patient. HITH often provides an alternative to admission to a hospital or an opportunity for earlier relocation to the home than would otherwise be possible.

Guide for use HITH suitability and assessment criteria are documented in the HITH guidelines, available at http://health.vic.gov.au/hith/guidelines.htm

Hypertensive disorder during pregnancy

Definition Hypertensive disorder during pregnancy includes pre-existing hypertensive disorders, hypertension arising in pregnancy and associated disorders such as eclampsia and preeclampsia.

Hypertension in pregnancy is defined as:

1. Systolic blood pressure greater than or equal to 140 mmHg and/or

2. Diastolic blood pressure greater than or equal to 90 mmHg.

Guide for use Measurements should be confirmed by repeated readings over several hours. Elevations of both systolic and diastolic blood pressures have been associated with adverse fetal outcome and therefore both are important.

Disorders associated with hypertension such as eclampsia and preeclampsia are further characterised by symptoms such as proteinuria, oedema or high body tempature.

This definition of hypertensive disorder in pregnancy from the Society of Obstetric Medicine in Australia and New Zealand (SOMANZ) aligns with the definition of the International Society for the Study of Hypertension in Pregnancy (ISSHP).


Primary postpartum haemorrhage

Definition Primary postpartum haemorrhage, a form of obstetric haemorrhage, is excessive bleeding from the genital tract after childbirth, occurring within 24 hours of birth.

Guide for use A blood loss of 500mls is the usual minimum amount for identification of postpartum haemorrhage however a woman’s haemodynamic instability is also taken into account, meaning that a smaller blood loss may be significant in a severely compromised woman.

Secondary postpartum haemorrhage is excessive bleeding from the genital tract after childbirth occurring between 24 hours and 6 weeks postpartum.

Registered nurse

Definition Registered nurses include persons with at least a three year training certificate and nurses holding post graduate qualifications. Registered nurses must be registered with the state/territory registration board. This is a comprehensive category and includes community mental health, general nurse, intellectual disability nurse, midwife (including pupil midwife), psychiatric nurse, senior nurse, charge nurse (now unit manager), supervisory nurse and nurse educator. This category also includes nurses engaged in administrative duties no matter what the extent of their engagement, for example, directors of nursing and assistant directors of nursing.


Modification to existing items

Live birth

Definition A live birth is defined by the World Health Organization to be the complete expulsion or extraction from the mother of a baby, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of the voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached. Each product of such a birth is considered live born.

The birth of an infant, regardless of maturity or birth weight, who breathes or shows any other sign of life after being born

Separation

Definition Separation is the process by which an episode of care for an admitted patient ceases. A separation may be formal or statistical.

Formal separation:

The administrative process by which a hospital records the cessation of treatment and/or care and/or accommodation of a patient.

Statistical separation:

The administrative process by which a hospital records the cessation of an episode of care for a patient within the one hospital stay.

The date on which the baby and/or mother is discharged from the place of birth.


Stillbirth (foetal death)

Definition Stillbirth is A foetal death prior to the complete expulsion or extraction from its mother of a product of conception of 20 or more completed weeks of gestation or of 400 grams or more birth weight.

The death is indicated by the fact that after such separation the foetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles.

Guide for use Terminations of pregnancy performed at gestational ages of 20 or more weeks should be included in perinatal collections and should be recorded either as stillbirths or, in the unlikely event of showing evidence of life, as live births.

Foetus papyraceous and foetus compressus are products of conception recognisable as a deceased foetus. These foetal deaths are likely to have occurred before 20 weeks gestation but should be included as stillbirths in perinatal collections if they are recognisable as a foetus and have been expelled or extracted with other products of conception at 20 or more weeks gestational age.


Section three: Data definitions

New items

Influenza vaccination status

Specification

Definition Whether or not the mother has received an influenza vaccine during this pregnancy

Representation class

Code Data type Number

Format N Field size 1

Location Episode record Position 125

Permissible values Code Descriptor

1 Influenza vaccine received at any time during this pregnancy

2 Influenza vaccine not received at any time during this pregnancy

9 Not stated / inadequately described

Reporting guide Report the statement that best describes the woman’s understanding of her influenza vaccine status for this pregnancy.

If the vaccination was received prior to this pregnancy, report code 2 - Influenza vaccine not received at any time during this pregnancy

Reported by All Victorian hospitals where a birth has occurred (including birth centres) and homebirth practitioners

Reported for All birth episodes

Related concepts (Section 2):

None specified

Related data items (this section):

None specified

Related business rules (Section 4):

Mandatory to report

Administration

Principal data users Consultative Council on Obstetric and Paediatric Mortality and Morbidity

Definition source Department of Health

Version 1. July 2015

Codeset source Department of Health

Collection start date 1 July 2015


Number of antenatal care visits

Specification

Definition The total number of antenatal care visits attended by a pregnant female


Total Data type Number

Format NN Field size 2


Permissible values Range: zero to 30 (inclusive)

Code Descriptor


Reporting guide Guide for use:

Antenatal care visits are attributed to the pregnant woman.

In rural and remote locations where a midwife or doctor is not employed, registered Aboriginal health workers and registered nurses may perform this role within the scope of their training and skill licence.

Include all pregnancy-related appointments with medical doctors where the medical officer has entered documentation related to that visit on the antenatal record.

An antenatal care visit does not include a visit where the sole purpose of contact is to confirm the pregnancy only, or those contacts that occurred during the pregnancy that related to other non-pregnancy related issues.

An antenatal care visit does not include a visit where the sole purpose of contact is to perform image screening, diagnostic testing or the collection of bloods or tissue for pathology testing. Exception to this rule is made when the health professional performing the procedure or test is a doctor or midwife and the appointment directly relates to this pregnancy and the health and wellbeing of the fetus.

Collection methods:

Collect the total number of antenatal care visits for which there is documentation included in the health record of pregnancy and/or birth. To be collected once, after the onset of labour. Include all medical specialist appointments or medical specialist clinic appointments where the provider of the service event has documented the visit on the health record.

Multiple visits on the same day should be recorded as one visit.




None specified



None specified


Mandatory to report

Administration


Definition source NHDD Version 1. July 2015

Codeset source NHDD Collection start date 1 July 2015


Pertussis (whooping cough) vaccination status

Specification

Definition Whether or not the mother has received a pertussis containing vaccine during this pregnancy


Code Data type Number

Format N Field size 1



1 Pertussis containing vaccine received at any time during this pregnancy

2 Pertussis containing vaccine not received at any time during this pregnancy


Reporting guide Report the statement that best describes the woman’s understanding of her pertussis (whooping cough) vaccine status for this pregnancy.

If the vaccination was received prior to this pregnancy, report code 2 - Pertussis containing vaccine not received at any time during this pregnancy




None specified


None specified


Mandatory to report

Administration



Version 1. July 2015

Codeset source Department of Health

Collection start date 1 July 2015


Modification to existing itemsPlease note, only specification and/or administrative attributes that are proposed for modification are described in this section. Specification and administrative attributes not listed for the data item below are proposed to remain unchanged from that specified in the ‘Victorian Perinatal Data Collection Manual, Second Edition V3.0, 2013’ available at http://www.health.vic.gov.au/ccopmm/vpdc/index.htm



Anaesthesia for operative delivery – type

Specification

Definition The type of anaesthesia administered to a woman during a birth event the mother for, or associated with, the operative delivery of the baby (forceps, vacuum/ventouse or caesarean section)


2 Local anaesthetic to perineum

3 Pudendal block

4 Epidural or caudal block

5 Spinal block

6 General anaesthetic

7 Combined spinal-epidural block

8 Other anaesthesia


Reporting guide This item should be recorded for operative or instrumental delivery of the baby only. It does not include the removal of the placenta.

Combined spinal-epidural block:

The spinal-epidural block combines the benefits of rapid action of a spinal block and the flexibility of an epidural block. An epidural catheter inserted during the technique enables the provision of long-lasting analgesia with the ability to titrate the dose for the desired effect.

Other anaesthesia:

May include parenteral opioids, nitrous oxide.

Operative delivery includes caesarean section, forceps and ventouse/vacuum extraction. A combination of up to four valid codes can be used. Do not report a value for birth episodes with no operative delivery, leave blank.

Code 7 Combined spinal-epidural (CSE): ‘Combined spinal-epidural analgesia most commonly involves insertion of an epidural needle into the lumbar epidural space, passage of the tip of a spinal needle through this epidural "introducer", spinal injection, and withdrawal of the needle, and then the insertion of an epidural catheter through the epidural needle for use after the spinal analgesia wanes’ (Eisenach, 1999).

Administration

Definition source NHDD Version 1. January 1999

2. July 2015


Analgesia for labour – type

Specification

Definition The type of analgesia administered to the woman during a birth event to relieve pain during labour


2 Nitrous oxide

3 Systemic opioids

4 Epidural or caudal block

5 Spinal block

7 Combined spinal - epidural block

8 Other analgesia


Reporting guide This item is to be recorded for first and second stage labour, but not for third stage labour, e.g. removal of placenta.

Systemic opioids:

Includes intramuscular and intravenous opioids.

Combined spinal-epidural block:

The spinal-epidural block combines the benefits of rapid action of a spinal block and the flexibility of an epidural block. An epidural catheter inserted during the technique enables the provision of long-lasting analgesia with the ability to titrate the dose for the desired effect.

Other analgesia:

Includes all non-narcotic oral analgesia. Includes non-pharmacological methods such as hypnosis, acupuncture, massage, relaxation techniques, temperature regulation, aroma therapy and other.

A combination of up to four valid codes can be used. Do not report a value of birth episodes where the mother does not have a labour, leave blank.

Analgesia will usually be administered by injection or inhalation. This item is to be recorded for first and second stage labour, but not third stage labour, for example removal of placenta, and not when it is used primarily to enable operative birth.

Code 7 Combined spinal-epidural: ‘Combined spinal-epidural analgesia (CSE) most commonly involves insertion of an epidural needle into the lumbar epidural space, passage of the tip of a spinal needle through this epidural ‘introducer’, spinal injection, and withdrawal of the needle, and then the insertion of an epidural catheter through the epidural needle for use after the spinal analgesia wanes.’1

1 Eisenach J C 1999, ‘Combined spinal-epidural analgesia in obstetrics’ Anesthesiology, vol. 91, no. 1, pp. 299–302.


Code 8 Other includes transcutaneous electrical nerve stimulation (TENS) and sterile water injections.

Administration


2. July 2015


Birth plurality

Specification

Reporting guide Plurality at birth is determined by the total number of live births and stillbirths that result from the pregnancy. Stillbirths, including those where the fetus was likely to have died before 20 weeks gestation, should be included in the count of plurality. To be included, they should be recognisable as a fetus and have been expelled or extracted with other products of conception when pregnancy ended at 20 or more weeks gestation.

Plurality of a birth is determined by the number of livebirths or by the number of fetuses that remain in utero at 20 weeks’ gestation and that are subsequently born separately. Include all livebirths and stillbirths. Fetuses aborted before 20 completed weeks are excluded. Fetuses compressed in the placenta at 20 or more weeks (fetus papyraceous) and expelled at time of delivery are included.

Administration


2. July 2015


Birth status

Specification

Definition Condition Status of the baby at birth

Reporting guide Live birth is the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy which, after such separation, breathes or shows any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached; each product of such a birth is considered liveborn (WHO, 1992 definition).

Stillbirth is a fetal death prior to the complete expulsion or extraction from its mother of a product of conception of 20 or more completed weeks of gestation or of 400 g or more birthweight; the death is indicated by the fact that after such separation the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles.

Code 1 Liveborn: CCOPMM defines liveborn as the birth of an infant, regardless of maturity or birth weight, who breathes or shows any other signs of life after being born.

Code 2 Stillborn (occurring before labour) and code 3 Stillborn (occurring during labour): CCOPMM defines a stillbirth as the birth of an infant of at least 20 weeks’ gestation or if gestation is unknown, weighing at least 400 grams, which shows no signs of life after birth.

Administration


2. July 2015


Birth weight

Specification

Definition The first weight, in grams, of the live-born or stillborn baby obtained after birth, or the weight of the neonate or infant on the date admitted if this is different from the date of birth.

The first weight (in grams) obtained after birth of a live born or stillborn baby

Reporting guide Unit of measure is in grams.

For livebirths, birth weight should preferably be measured within the first few hours after birth before significant postnatal weight loss has occurred. While statistical tabulations include 500g groupings for birthweight, weights should not be recorded in those groupings. The actual weight should be recorded to the degree of accuracy to which it is measured.

In the case of babies born before arrival at the hospital, the birth weight should be taken shortly after the baby has been admitted to hospital.

Administration

Definition source NHDD (Department of Health modified)

Version 1. January 1982

2. July 2015


Congenital anomalies – free text

Specification

Reporting guide Specify the defect(s) or congenital anomaly(ies) with as much detail as possible, for example; cleft lip and palate – unilateral/left or right. If a baby is diagnosed with a syndrome, then it should be specified with the other associated conditions; for example, Down syndrome with associated congenital heart disease and/or duodenal atresia. When congenital anomalies are reported, the name and surname of the paediatrician must should be reported in First given name – paediatrician and Surname/family name – paediatrician where applicable.


Congenital anomalies – indicator

Specification

Reporting guide Where congenital anomalies are identified, please specify details in Congenital Anomalies - Free Text and report First Given Name - Paediatrician and Surname / Family Name - Paediatrician where applicable.

If code 1 Congenital anomalies identified is reported, specify the anomaly. When congenital anomalies are reported, the name and surname of the paediatrician must be reported in First given name – paediatrician and Surname / family name – paediatrician.


Country of birth

Specification

Permissible values Please refer to the 'Country of birth and country of residence SACC codeset’ – effective 1 July 2012 (Excel file 48KB) – updated 30 December 2011'. The file may be found available at http://www.health.vic.gov.au/hdss/reffiles/index.htm


http://www.health.vic.gov.au/hdss/reffiles/index.htm

Events of labour and birth – ICD-10-AM code

Specification

Permissible values ICD-10-AM/ACHI (8th edition) available on request, please email [email protected].

Please refer to: http://www.health.vic.gov.au/hdss/archive/reffiles/2009-10/libfile/libfil09.htm file ‘ICD-10-AM library file 2009–10 (zipped Excel file 2.37MB)'.

Code Descriptor

O142 HELLP Syndrome

O660 Shoulder dystocia

O839 Water birth

Z292 Antibiotic therapy in labour

Administration


2. January 2015

Codeset source ICD-10-AM sixth eighth edition

Collection start date 2009


http://www.health.vic.gov.au/hdss/archive/reffiles/2009-10/libfile/libfil09.htm


First given name – paediatrician

Specification

Reporting guide The given name(s) of the paediatrician. If the baby is not referred to a paediatrician, leave blank. If the birth is a termination for congenital abnormality, report the given name(s) of the medical officer responsible for the women’s care.


Hospital code (agency identifier)

Specification

Permissible values Please refer to the 'Hospital Code Table’ (Excel File 90KB) – Updated 26 February 2013’. The file may be found available at http://www.health.vic.gov.au/hdss/reffiles/index.htm



Indication for induction – ICD-10-AM code

Specification



Code Descriptor

O142 HELLP Syndrome

O480 No medical indication

Administration



2. January 2009

3. July 2015






Indications for operative delivery – ICD-10-AM code

Specification


Please refer to: http://www.health.vic.gov.au/hdss/archive/reffiles/2009-10/libfile/libfil09.htm file 'ICD-10-AM library file 2009–10 (zipped Excel file 2.37MB)'.

Code Descriptor

O142 HELLP Syndrome

O480 No medical indication

Administration



2. January 1999

3. January 2009

4. July 2015




Labour type

Specification

Reporting guide Labour commences at the onset of regular uterine contractions, which act to produce progressive cervical dilatation, and is distinct from spurious labour or pre-labour rupture of membranes.

If prostaglandins were given to induce labour and there is no resulting labour until after 24 hours, then code the onset of labour as spontaneous.

A combination of up to three valid codes can be reported.

Spontaneous: labour occurs naturally without any intervention. This includes births where prostaglandin is used to induce but onset of labour does not occur within 48 hours of administration.

Induction of labour: a procedure performed for the purpose of initiating and establishing labour, either medically and/or surgically.

Augmentation of labour: spontaneous onset of labour complemented with the use of drugs such as oxytocins, prostaglandins or their derivatives, and/or artificial rupture of membranes (ARM) either by hindwater or forewater rupture. If labour was augmented, select and record both spontaneous and augmented in Labour type. Code 4 Augmented cannot be reported on its own.

No labour: indicates the total absence of labour, as in an elective caesarean or a failed induction. If a failed induction occurred, that is, the mother failed to establish labour, select both the induction type (medical, surgical or both) and no labour.

An induction, medical and/or surgical cannot be recorded with augmentation. If an induction has occurred, record the reason in Indication for induction.

Administration

Definition source NHDD (DH modified)


2. July 2015


Last birth – caesarean section indicator

Specification

Definition An indicator of whether a caesarean section was performed for the most recent previous pregnancy that resulted in a birth

Whether a caesarean section was performed for the mother's last previous birth

Administration


2. January 2009

3. July 2015


Maternal medical conditions – ICD-10-AM code

Specification



Code Descriptor

O100 Pre-existing essential hypertension complicating pregnancy, childbirth and the puerperium

O142 HELLP Syndrome

O240 Pre-existing diabetes mellitus, type 1, in pregnancy

O2419 Pre-existing diabetes mellitus, type 2, in pregnancy, unspecified

O2681 Renal disease, pregnancy related

O993 Mental disorders and diseases of the nervous system complicating pregnancy, childbirth and the puerperium (psychosocial problems)

O994 Diseases of the circulatory system complicating pregnancy, childbirth and the puerperium

Administration


2. January 1999

3. January 2009

4. July 2015






Maternal smoking at less than 20 weeks

Specification

Definition A self-reported indicator of whether a pregnant woman smoked tobacco at any time during the first 20 weeks of her pregnancy

Cigarette smoking before 20 weeks’ gestation

Administration



2. July 2015


Maternal smoking at more than or equal to 20 weeks

Specification

Definition The self-reported number of cigarettes usually smoked daily by a pregnant woman after the first 20 weeks of pregnancy until the birth

Cigarette smoking at 20 or more weeks’ gestation

Reporting guide Data should be collected after the birth.

‘After 20 weeks’ is defined as greater than or equal to 20 completed weeks’ gestation (>=20 weeks + 0 days).

‘Usually’ is defined as ‘according to established, or frequent usage; commonly, ordinarily; as a rule’.

If a woman reports having quit smoking at some point between 20 weeks of pregnancy and the birth, the value recorded should be the number of cigarettes usually smoked daily prior to quitting.

If she the woman smokes tobacco, but not cigarettes, estimate the number of cigarettes that would approximate the amount of tobacco used, for example, in a pipe.

Report the mother’s stated average number of cigarettes smoked per day.

Administration



2. July 2015


Method of birth

Specification

Format NN Field size 21



1 Forceps

3 Vaginal birth – non-instrumental

4 Planned caesarean – no labour

5 Unplanned caesarean – labour

6 Planned caesarean – labour

7 Unplanned caesarean – no labour

8 Vacuum extraction


10 Other opertaive birth

Reporting guide In the case of multiple births, the method of birth is reported in each baby’s episode record.

Where forceps/vacuum extraction are used to assist the extraction of the baby at caesarean section, code as a caesarian section.

Where a hysterotomy is performed to extract the baby, code as caesarean section.

Code 1 Forceps

Includes any use of forceps in a vaginal birth – rotation, delivery and forceps to the head during breech presentations. Includes vaginal breech with forceps to the after coming head

Code 3 Vaginal birth – non-instrumental

Includes manual assistance for example, a vaginal breech that has been manually rotated

Code 4 Planned caesarean – no labour

Caesarean takes place as a planned procedure before the onset of labour

Code 5 Unplanned caesarean

Caesarean is undertaken for a complication after the onset of labour, whether that onset is spontaneous or induced

Code 6 Planned caesarean – labour

Caesarean was a planned procedure, but occurs after spontaneous onset of labour

Code 7 Unplanned caesarean – no labour

Procedure is undertaken for an urgent indication before the onset of labour. If a women is planning to have a caesarean for a non-


urgent indication (for example, repeat caesarean, breech), then develops an urgent indication (for example, cord prolapse, antepartum haemorrhage) that becomes the immediate indication for the caesarean, code it as unplanned (code 5 or 7), either in labour or not in labour as appropriate.

Code 10 Other operative birth

Includes D&C, D&E, hysterotomy and laparotomy.

Excludes operative methods of birth for which a specific code exists.

Administration


2. January 1999

3. January 2009

4. July 2015

[Note this revision has partially been made in version 3.0 of the manual.]


Neonatal morbidity – ICD-10-AM code

Specification



Administration



2. January 1999

3. January 2009

4. July 2015






Obstetric complications – ICD-10-AM code

Specification



Code Descriptor

O142 HELLP Syndrome

O149 Pre-eclampsia, unspecified

O2442 Diabetes mellitus arising at or after 24 weeks’ gestation, insulin treated

O2444 Diabetes mellitus arising at or after 24 weeks’ gestation, diet controlled

O365 Suspected fetal growth restriction

O440 Placenta praevia without haemorrhage

O441 Placenta praevia with haemorrhage

O459 Premature separation of placenta (abruptio placentae)

O468 Other antepartum haemorrhage

Z223 Carrier of streptococcus group B (GBS+)

Administration


2. July 2015






Parity

Specification

Reporting guide To calculate parity, count all previous pregnancies that resulted in a live birth or a stillbirth of at least 20 weeks gestation or at least 400 grams birthweight. Excluded from the count are:

the current pregnancy;

pregnancies resulting in spontaneous or induced abortions before 20 weeks gestation; and

ectopic pregnancies.

A primigravida (a woman giving birth for the first time) has a parity of 00.

A pregnancy with multiple fetuses is counted as one pregnancy.

If this is the first pregnancy, record 00 (Primipara). Record the number of known previous pregnancies that ended in a stillborn at 20 or more weeks’ gestation or livebirths of any gestation (including those that resulted in a subsequent death). Do not include the current pregnancy. Pregnancies of multiple fetuses should be counted as only one pregnancy. For example, a twin pregnancy is counted as one pregnancy, even though it has two outcomes. A woman who is currently pregnant and has had one singleton birth and one set of twins is parity 2. A woman who is currently pregnant and had one set of twins who both died at two days of age is parity 1.

Administration

Definition source NHDD METeOR identifier: 302013


2. July 2015


Perineal/genital laceration – degree / type

Specification


1 First degree laceration / tear

2 Second degree laceration / tear

3 Third degree laceration / tear

4 Fourth degree laceration / tear

5 Labial / clitoral laceration / tear

6 Vaginal wall laceration / tear

7 Cervical laceration / tear

8 Other laceration, rupture or tear


Reporting guide First degree laceration/vaginal graze:

Graze, laceration, rupture or tear of the perineal skin during delivery that may be considered to be slight or that involves one or more of the following structures: fourchette, labia, vagina and / or vulva.

Second degree laceration :

Perineal laceration, rupture or tear as in Code 1 occurring during delivery, also involving: pelvic floor, perineal muscles, vaginal and / or muscles.

Third degree laceration:

Perineal laceration, rupture or tear as in Code 2 occurring during delivery, also involving: anal sphincter, rectovaginal septum and / sphincter not otherwise specified. Excludes laceration involving the anal or rectal mucosa.

Fourth degree laceration

Perineal laceration, rupture or tear as in Code 3 occurring during delivery, also involving: anal mucosa and / or rectal mucosa.

Other perineal laceration, rupture or tear:

May include haematoma or unspecified perineal tear.

Administration



2. July 2015


Postpartum complications – ICD-10-AM code

Specification



Code Descriptor

O142 HELLP Syndrome

Administration


2. July 2015






Procedure – ACHI code

Specification



Code Descriptor

1651100 Cervical suture for cervical shortening

9619703 Intramuscular administration of two doses of steroids antenatally

Administration

Definition source DH Version 1. January 1982

2. January 2009

3. July 2015






Residential locality

Specification

Permissible values Please refer to the ‘Postcode - Locality reference file’ (Excel File 4.28MB) – Updated 19 December 2012’. The file may be found available at http://www.health.vic.gov.au/hdss/reffiles/index.htm



Residential postcode

Specification

Permissible values Please refer to the ‘Postcode - Locality reference file’ (Excel File 4.28MB) – Updated 19 December 2012’. The file may be found available at http://www.health.vic.gov.au/hdss/reffiles/index.htm

Code Descriptor

1000 No fixed abode

8888 Overseas (report the four digit country code in the locality field)

9988 Unknown




Residential road suffix code – mother

Specification

Permissible values Codeset available on request, please email [email protected].


Residential road type – mother

Specification

Permissible values Codeset available on request, please email [email protected].


Separation status – baby

Specification


1 Discharged

2 Died

3 Transferred

4 Transferred and died

5 Infant Death


Reporting guide Do not report a value for stillbirth episodes, leave blank.

The Clinical Councils Unit also assigns this code retrospectively, through their links with the CCOPMM.

For babies who are transferred to Hospital in the Home (HITH), the Separation status – baby is code 3 Transferred, the Separation date is the date the transfer to HITH occurs and the Transfer destination – baby is the campus code of the campus providing the HITH service.

Code 5 Infant death: death occurring between 29 and 364 days after birth.

Administration



2. July 2015


Separation status – mother

Specification


1 Discharged

2 Died

3 Transferred



Administration



2. July 2015


Setting of birth – actual

Specification


Code Descriptor

NNNN Hospital code

0002 Birth centre

0003 Home (other)

0005 In transit

0006 Home – Private midwife care

0007 Home – Public homebirth program

0008 Other - specify




Setting of birth – intended

Specification


Code Descriptor

NNNN Hospital code

0002 Birth centre

0003 Home (other)

0006 Home – Private midwife care

0007 Home – Public homebirth program

0008 Other - specify




Surname / family name – paediatrician

Specification

Reporting guide The surname of the paediatrician. If the baby is not referred to a paediatrician, leave blank. If the birth is a termination for congenital abnormality, report the surname of the medical officer responsible for the woman’s care.


Transfer destination – baby

Specification


Code Descriptor


Refer to the Hospital Code Table reference file available from:





Transfer destination – mother

Specification


Code Descriptor


Refer to the Hospital Code Table reference file available from:




Version identifier

Specification


2009

2015

Administration



2. July 2015


Section four: Business rules

New items

Admission to special care nursery (SCN) / neonatal intensive care unit (NICU) – baby, Setting of birth – actual and Hospital code (agency identifier) valid combinations

If Admission to special care nursery (SCN) / neonatal intensive care unit (NICU) – baby is:

1 Admitted to SCN or

2 Admitted to NICU

Setting of birth – actual must be: and Hospital code (agency identifier) must be:

A health service from the list below with SCN and/or NICU services

Equal to Setting of birth – actual

0002 Birth centre or

0003 Home (other) or

0005 In transit or

0006 Home – Private midwife care or

0007 Home – Public homebirth program or

0008 Other – specify

A health service from the list below with SCN and/or NICU services


Campuses with a SCN or NICU

Campus Code

Campus Name SCN NICU

1660 Albury Wodonga Health - Wodonga Yes No

1590 Angliss Hospital Yes No

2010 Ballarat Health Services [Base Campus] Yes No

6291 Bays Hospital, The [Mornington] Yes No

1021 Bendigo Hospital, The Yes No

1050 Box Hill Hospital Yes No

6511 Cabrini Malvern Yes No

3660 Casey Hospital Yes No

2060 Central Gippsland Health Service [Sale] Yes No

2111 Dandenong Campus Yes No

6470 Epworth Freemasons Yes No

2220 Frankston Hospital Yes No

2050 Geelong Hospital Yes No

1121 Goulburn Valley Health [Shepparton] Yes No

8890 Jessie McPherson Private Hospital [Clayton] Yes No

6400 Knox Private Hospital [Wantirna] Yes No

2440 Latrobe Regional Hospital [Traralgon] Yes No

1160 Mercy Hospital for Women Yes Yes

1320 Mercy Public Hospitals Inc [Werribee] Yes No

8440 Mitcham Private Hospital Yes No

1170 Monash Medical Centre [Clayton] Yes Yes

2320 New Mildura Base Hospital Yes No

1150 Northeast Health Wangaratta Yes No

1280 Northern Hospital, The [Epping] Yes No

7390 Northpark Private Hospital [Bundoora] Yes No

6790 Peninsula Private Hospital [Frankston] Yes No

1230 Royal Womens Hospital [Carlton] Yes Yes

1360 Sandringham & District Memorial Hospital Yes No

2160 South West Healthcare [Warrnambool] Yes No

6520 St John of God Ballarat Hospital Yes No

6030 St John of God Bendigo Hospital Yes No

6030 St John of God Bendigo Hospital Yes No

6080 St John of God Berwick Hospital Yes No

6550 St John of God Geelong Hospital Yes No


6620 St Vincents Private Hospital Fitzroy Yes No

1390 Sunshine Hospital Yes No

6600 Waverley Private Hospital [Mt Waverley] Yes No

1580 West Gippsland Healthcare Group [Warragul] Yes No

2170 Wimmera Base Hospital [Horsham] Yes No


Discipline of antenatal care provider and Number of antenatal care visits valid combinations

If Discipline of antenatal care provider is: Number of antenatal care visits must be:

1 - Obstetrician or

2 - Midwife or

3 - General practitioner or

8 - Other

Equal to or greater than 01

4 - No antenatal care provider 00

Fetal monitoring in labour and Labour Type valid combinations

If Labour Type is: Fetal monitoring in labour must be:

5 No labour or

2 Induced medical and 5 No labour or

3 Induced surgical and 5 No labour or

2 Induced medical and 3 Induced surgical and 5 No labour

01 None

Gestational age at first antenatal visit and Number of antenatal care visits valid combinations

If Gestational age at first antenatal visit is: Number of antenatal care visits must be:

Between 02 and 45 (inclusive) Equal to or greater than 01

88 - No antenatal care 00


Modification to existing items

Anaesthesia for operative delivery – indicator and Method of birth valid combinations

When anaesthesia for operative delivery – indicator is:

Method of birth must be:

Blank 3 Vaginal birth – non-instrumental

1 Anaesthesia administered 1 Forceps or

4 Planned caesarean – no labour or

5 Unplanned caesarean – labour or

6 Planned caesarean – labour or

7 Unplanned caesarean – no labour or

8 Vacuum extraction

10 Other operative birth

2 Anaesthesia not administered 1 Forceps

or

8 Vacuum extraction

[Note this revision has already been made in version 3.0 of the manual.]

Congenital anomalies – indicator and Congenital anomalies – free text conditionally mandatory data item

If Congenital anomalies – indicator is: then the following item cannot be blank:

1 Congenital anomalies identified Congenital anomalies – free text

First given name - paediatrician

Surname / family name - paediatrician



Mandatory to report data items

A valid value must be reported for the following data items. The value must not be a code for the descriptor ‘Not stated/Inadequately described’, as available for some of these items.

Admission to high dependency unit (HDU) / intensive care unit (ICU) – mother

Admitted patient election status – mother

Artificial reproductive technology – indicator

Birth order

Birth plurality

Birth presentation

Birth status

Birth weight

Blood product transfusion – mother

Collection identifier

Congenital anomalies – indicator

Country of birth

Date of admission – mother

Date of birth – baby

Date of birth – mother

Date of onset of labour

Date of onset of second stage of labour

Date of rupture of membranes

Discipline of antenatal care provider

Discipline of lead intra-partum care provider

Episiotomy – indicator

Estimated blood loss (ml)

Estimated date of confinement

Estimated gestational age

Fetal monitoring in labour

First given name – mother

Gestational age at first antenatal visit

Gravidity

Height – self-reported – mother

Hospital code (agency identifier)

Indigenous status – baby

Indigenous status – mother

Influenza vaccination status


Labour type

Marital status

Maternal smoking < 20 weeks

Maternal smoking ≥ 20 weeks

Method of birth

Number of antenatal care visits

Number of ultrasounds ≥ 27 weeks

Number of ultrasounds 10–14 weeks

Number of ultrasounds 15–26 weeks

Parity

Patient identifier – mother

Perineal laceration – indicator

Pertussis (whooping cough) vaccination status

Prophylactic oxytocin in third stage

Residential locality

Residential postcode

Resuscitation method – drugs

Resuscitation method – mechanical

Separation date – mother

Separation status – mother

Setting of birth – actual

Sex – baby

Surname / family name – mother

Time of birth

Time of onset of labour

Time of onset of second stage of labour

Time of rupture of membranes

Time to established respiration (TER)

Total number of previous abortions – induced

Total number of previous abortions – spontaneous

Total number of previous caesareans

Total number of previous ectopic pregnancies

Total number of previous live births

Total number of previous neonatal deaths

Total number of previous stillbirths (fetal deaths)

Total number of previous unknown outcomes of pregnancy

Transaction type flag


Version identifier

Weight – self-reported – mother


Separation status – baby and Transfer destination – baby conditionally mandatory data item

If Separation status – baby is: then the following item cannot be blank:

3 – Transferred

4 – Transferred and died

Transfer destination – baby

Separation status – mother and Transfer destination – mother – conditionally mandatory data item

If Separation status – mother is: then the following item cannot be blank:

3 Transferred


Transfer destination – mother


Discontinued items

Anaesthesia for operative delivery – indicator and Anaesthesia for operative delivery – type valid combinations

When Anaesthesia for operative delivery – indicator is code 1 Anaesthesia administered – type valid, Anaesthesia for operative delivery – type codes are:

Single codes:


3 Pudendal

4 Epidural or caudal

5 Spinal

6 General anaesthetic

7 Combined spinal-epidural

8 Other


Two-code combinations:

2 Local anaesthetic to perineum 3 Pudendal

2 Local anaesthetic to perineum 4 Epidural or caudal

2 Local anaesthetic to perineum 5 Spinal

2 Local anaesthetic to perineum 6 General anaesthetic

2 Local anaesthetic to perineum 7 Combined spinal-epidural

2 Local anaesthetic to perineum 8 Other

3 Pudendal 4 Epidural or caudal

3 Pudendal 5 Spinal

3 Pudendal 6 General anaesthetic

3 Pudendal 7 Combined spinal-epidural

3 Pudendal 8 Other

4 Epidural or caudal 5 Spinal

4 Epidural or caudal 6 General anaesthetic

4 Epidural or caudal 8 Other

5 Spinal 6 General anaesthetic

5 Spinal 8 Other

6 General anaesthetic 7 Combined spinal-epidural

6 General anaesthetic 8 Other

7 Combined spinal-epidural 8 Other

Three-code combinations:



3 Pudendal 4 Epidural or caudal


3 Pudendal 5 Spinal


3 Pudendal 6 General anaesthetic


3 Pudendal 8 Other

3 Pudendal 4 Epidural or caudal 5 Spinal

3 Pudendal 4 Epidural or caudal 6 General anaesthetic

4 Epidural or caudal 5 Spinal 6 General anaesthetic

Four-code combinations:


3 Pudendal 4 Epidural or caudal 6 General anaesthetic


3 Pudendal 5 Spinal 6 General anaesthetic

Analgesia for labour – indicator and Analgesia for labour – type valid combinations

When Analgesia for labour – indicator is code 1 – Analgesia administered, valid Analgesia for labour – type codes are:

Single codes:

2 Nitrous oxide

3 Systemic opioids

4 Epidural or caudal

5 Spinal

7 Combined spinal-epidural

8 Other


Two-code combinations:

2 Nitrous oxide 3 Systemic opioids

2 Nitrous oxide 4 Epidural or caudal

2 Nitrous oxide 5 Spinal

2 Nitrous oxide 7 Combined spinal-epidural

2 Nitrous oxide 8 Other

3 Systemic opioids 4 Epidural or caudal

3 Systemic opioids 5 Spinal

3 Systemic opioids 7 Combined spinal-epidural


3 Systemic opioids 8 Other

4 Epidural or caudal 5 Spinal

4 Epidural or caudal 8 Other

5 Spinal 8 Other

7 Combined spinal-epidural 8 Other

Three-code combinations:

2 Nitrous oxide 3 Systemic opioids 4 Epidural or caudal

2 Nitrous oxide 3 Systemic opioids 5 Spinal

2 Nitrous oxide 3 Systemic opioids 7 Combined spinal-epidural

2 Nitrous oxide 3 Systemic opioids 8 Other

2 Nitrous oxide 4 Epidural or caudal 8 Other

2 Nitrous oxide 5 Spinal 8 Other

2 Nitrous oxide 7 Combined spinal - epidural 8 Other

3 Systemic opioids 4 Epidural or caudal 8 Other

3 Systemic opioids 5 Spinal 8 Other

3 Systemic opioids 7 Combined spinal – epidural 8 Other

Four-code combinations:

2 Nitrous oxide 3 Systemic opioids 4 Epidural or caudal 8 Other

2 Nitrous oxide 3 Systemic opioids 5 Spinal 8 Other

2 Nitrous oxide 3 Systemic opioids 7 Combined spinal – epidural

8 Other

2 Nitrous oxide 3 Systemic opioids 4 Epidural or caudal 8 Other

Discipline of lead intrapartum care provider and Setting of birth - actual valid combinations

If Setting of birth is: Discipline of lead intrapartum Care Provider must be:

0003 Home (other) or

0005 In transit

2 Midwife or

3 General practitioner or

4 No intrapartum care provider


Method of birth ‘Other operative delivery’ and associated data items valid combinations

If Method of birth is:

10 Other operative birth


the data items listed below must be:

Data item:

Labour type

Value:

1 Spontaneous or

1 Spontaneous and 4 Augmented or

2 Induced medical or

2 Induced medical and 3 Induced surgical or

2 Induced medical and 3 Induced surgical and 5 No labour or

2 Induced medical and 5 No labour or

5 No labour or

3 Induced surgical or

3 Induced surgical and 5 No labour or

5 No labour

Indications for operative delivery - ICD-10-AM code or Indications for operative delivery - free text

Must not be blank

Obstetric complications – ICD-10-AM code or Obstetric complications – Free text

Must not be blank

Procedures – ACHI code or

Procedures – Free Text*

Must not be blank

Valid code and descriptors for reporting with ‘Method of birth - 10 Other operative delivery’ in the data item Procedures – ACHI code include:

3564000 Dilation and curettage of uterus [D&C] 3564303 Dilation and evacuation of uterus [D&E] 3564900 Hysterotomy 30373092 Laparotomy to assist birth


2 VPDC created code


Section five: Submission and compilation

This section of the manual provides the specifications for compiling a VPDC submission, including summary statistics and technical specifications. The proposals for revisions pertaining to this section include modifications to the episode records and file structure specifications, and the data submission timelines.

Episode records

Position number

Data item name Data type Format Field size

1 Collection identifier String AAAA 4

2 Version identifier Number NNNN 4

3 Transaction type flag String A 1

4 Hospital code (agency identifier) Number NNNN 4

5 Patient identifier – mother String A(10) 10

6 Patient identifier – baby String A(10) 10

7 Date of admission – mother Date/time DDMMCCYY 8

8 Surname / family name – mother String A(40) 40

9 First given name – mother String A(40) 40

10 Middle name – mother String A(40) 40

11 Residential locality String A(46) 46

12 Residential postcode Number NNNN 4

13 Residential road number – mother String A(300) 12

14 Residential road name – mother String A(45) 45

15 Residential road suffix code – mother String AA 2

16 Residential road type – mother String AAAA 4

17 Admitted patient election status – mother Number N 1

18 Country of birth Number NNNN 4

19 Indigenous status – mother Number N 1

20 Indigenous status – baby Number N 1

21 Marital status Number N 1


22 Date of birth – mother Date/time DDMMCCYY 8

23 Height – self-reported – mother Number NNN 3

24 Weight – self-reported – mother Number NN[N] 3

25 Setting of birth – intended Number NNNN 4

26 Setting of birth – intended – other specified description

String A(20) 20

27 Setting of birth – actual Number NNNN 4

28 Setting of birth – actual – other specified description

String A(20) 20

29 Setting of birth – change of intent Number N 1

30 Setting of birth – change of intent – reason Number N 1

31 Maternal smoking at less than 20 weeks Number N 1

32 Maternal smoking at more than or equal to 20 weeks

Number NN 2

33 Gravidity Number N[N] 2

34 Total number of previous live births Number NN 2

35 Parity Number NN 2

36 Total number of previous stillbirths (fetal deaths)

Number NN 2

37 Total number of previous neonatal deaths Number NN 2

38 Total number of previous abortions – spontaneous

Number NN 2

39 Total number of previous abortions – induced Number NN 2

40 Total number of previous ectopic pregnancies Number NN 2

41 Total number of previous unknown outcomes of pregnancy

Number NN 2

42 Date of completion of last pregnancy Date/time {DD}MMCCYY

6 (8)

43 Outcome of last pregnancy Number N 1

44 Last birth – caesarean section indicator Number N 1


45 Total number of previous caesareans Number NN 2

46 Plan for vaginal birth after caesarean Number N 1

47 Estimated date of confinement Date/time DDMMCCYY 8

48 Estimated gestational age Number NN 2

49 Maternal medical conditions – free text String A(300) 300

50 Maternal medical conditions – ICD-10-AM code String ANN[NN] 5 (X12)

51 Obstetric complications – free text String A(300) 300

52 Obstetric complications – ICD-10-AM code String ANN[NN] 5 (x15)

53 Gestational age at first antenatal visit Number N[N] 2

54 Discipline of antenatal care provider Number N 1

55 Procedure – free text String A(300) 300

56 Procedure – ACHI code Number NNNNNNN 7 (x8)

57 Number of ultrasounds 10–14 weeks Number NN 2

58 Number of ultrasounds 15–26 weeks Number NN 2

59 Number of ultrasounds at or after 27 weeks Number NN 2

60 Artificial reproductive technology – indicator Number N 1

61 Date of onset of labour Date/time DDMMCCYY 8

62 Time of onset of labour Date/time HHMM 4

63 Date of onset of second stage of labour Date/time DDMMCCYY 8

64 Time of onset of second stage of labour Date/time HHMM 4

65 Date of rupture of membranes Date/time DDMMCCYY 8

66 Time of rupture of membranes Date/time HHMM 4

67 Labour type Number N 1 (x3)

68 Labour induction/augmentation agent Number N 1 (x3)

69 Labour induction/augmentation agent – other specified description

String A(20) 20

70 Indication for induction – free text String A(50) 50

71 Indication for induction – ICD-10-AM code String ANN[NN] 5 (X1)

72 Fetal monitoring in labour String NN 2 (x7)


73 Birth presentation Number N 1

74 Method of birth Number NN 12

75 Indications for operative delivery – free text String A(300) 300

76 Indications for operative delivery – ICD-10-AM code

String ANN[NN] 5 (x4)

77 Analgesia for labour – indicator Number N 1

78 Analgesia for labour – type Number N 1 (x4)

79 Anaesthesia for operative delivery – indicator Number N 1

80 Anaesthesia for operative delivery – type Number N 1 (x4)

81 Events of labour and birth – free text String A(300) 300

82 Events of labour and birth – ICD-10-AM code String ANN[NN] 5 (x9)

83 Prophylactic oxytocin in third stage Number N 1

84 Manual removal of placenta Number N 1

85 Perineal laceration – indicator Number N 1

86 Perineal/genital laceration – degree/type Number N 1 (x2)

87 Perineal laceration – repair Number N 1

88 Episiotomy – indicator Number N 1

89 Estimated blood loss (ml) Number N[NNNN] 5

90 Blood product transfusion – mother Number N 1

91 Postpartum complications – free text String A(300) 300

92 Postpartum complications – ICD-10-AM code String ANN[NN] 5 (x6)

93 Discipline of lead intrapartum care provider Number N 1

94 Admission to high dependency unit (HDU) / intensive care unit (ICU) – mother

Number N 1

95 Date of birth – baby Date/time DDMMCCYY 8

96 Time of birth Date/time HHMM 4

97 Sex – baby Number N 1

98 Birth plurality Number N 1


99 Birth order Number N 1

100 Birth status Number N 1

101 Birth weight Number NN[NN] 4

102 Apgar score at one minute Number N[N] 2

103 Apgar score at five minutes Number N[N] 2

104 Time to established respiration Number NN 2

105 Resuscitation method – mechanical String NN 2 (x10)

106 Resuscitation method – drugs Number N 1 (x5)

107 Congenital anomalies – indicator Number N 1

108 Congenital anomalies – free text String A(300) 300

109 Surname / family name – paediatrician String A(40) 40

110 First given name – paediatrician String A(40) 40

111 Neonatal morbidity – free text String A(300) 300

112 Neonatal morbidity – ICD-10-AM code String ANN[NN] 5 (x10)

113 Admission to special care nursery (SCN) / neonatal intensive care unit (NICU) – baby

Number N 1

114 Hepatitis B vaccine received Number N 1

115 Breastfeeding attempted Number N 1

116 Formula given in hospital Number N 1

117 Last feed before discharge taken exclusively from the breast

Number N 1

118 Separation date – mother Date/time DDMMCCYY 8

119 Separation date – baby Date/time DDMMCCYY 8

120 Separation status – mother Number N 1

121 Separation status – baby Number N 1

122 Transfer destination – mother Number NNNN 4

123 Transfer destination – baby Number NNNN 4

124 Number of antenatal care visits Number NN 2

125 Influenza vaccination status Number N 1


126 Pertussis (whooping cough) vaccination status Number N 1


File Structure Specifications

Header record

The header record must be included as the first record of all transmission files reported to the VPDC.

Episode records within a data submission file must be reported as per the version of the data collection as specified in the header record. For example, to submit new records for births between 1 June 2015 and 31 July 2015, two data submission files are to be compiled:

The first containing records for births from 1 June 2015 to 30 June 2015 (inclusive) as per the appropriate specifications with the version identifier reported as ‘2009’ in the header and episode records

The second containing records for births from 1 July 2015 to 31 July 2015 (inclusive) as per the appropriate specifications with the version identifier reported as ‘2015’ in the header and episode records

The convention for naming is:

CCCC | VVVV | NNNN | YYYYMMDDhhmm | TT | NNNNN | AAA…AAA

where:

CCCC: Collection identifier

VVVV: Version identifier

NNNN: Hospital code (agency identifier)

YYYYMMDDhhmm: Data submission identifier

TT: Submission number

NNNNN: Number of records following

AAA…AAA: Name of software


Data submission timelines

Birth period (from) Birth period (to) First submission expected by

Final submission due

1/01/2015 31/03/2015 30/04/2015 29/06/2015

1/04/2015 30/06/2015 30/07/2015 28/09/2015

1/07/2015 30/09/2015 30/10/2015 29/12/2015

1/10/2015 31/12/2015 30/01/2016 31/03/2016

1/01/2016 31/03/2016 30/04/2016 29/06/2016

1/04/2016 30/06/2016 30/07/2016 28/09/2016

From a business perspective data is required to be submitted within 30 days from the Date of birth – baby, however a maximum of 90 days is permitted under the Public Health and Wellbeing Regulations 2009. This includes corrections to remediate business rule violations and any additional updates to the birth record. Exceptions to this rule are only permissible where negotiated on a case by case basis.

To meet this requirement, at least one submission is required for each calendar month. Experience has shown that the review and correction of any submission issues is easiest close to the clinical event. Therefore agencies with high birth counts will benefit from a more regular submission cycle, such as fortnightly or weekly.

The episode record for a particular birth episode must include all the components known at the time. Where mother and / or baby are still admitted after the first or final submission due date, report all data items known at the time of submission.

While it is understood that the episode is unseparated for mothers and/or babies still admitted after 30 days it is recommended that those data items that are able to be reported are submitted at that time.

All edits triggered via the submission process should be resolved as soon as possible but up to 30 days from the date of notification of the edit is allowed.

Data quality is of the utmost importance; therefore there is no time limit on submitting updates or corrections to data previously submitted to the VPDC. To this end, it is possible to send further updates and corrections to data as required.


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