Section 3: Data Definitions
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Section 3: Data definitions Victorian Perinatal Data Collection (VPDC) manual Version 6.0 Department of Health and Human Services Victorian Perinatal Data Collection manual, version 6.0 If you would like to receive this publication in an accessible format, please email: [email protected] This document is available as a PDF on the internet at: https://www2.health.vic.gov.au/hospitals-and-health-services/quality-safety-service/consultative- councils/council-obstetric-paediatric-mortality/perinatal-data-collection © Copyright, State of Victoria, Department of Health and Human Services, 2018 This publication is copyright, no part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968. Authorised and published by the Victorian Government, 50 Lonsdale Street, Melbourne. January 2018 Page 1 Victorian Perinatal Data Collection manual, version 6.0 Contents Contents 2 Introduction 7 Admission to high dependency unit (HDU) / intensive care unit (ICU) – mother 8 Admission to special care nursery (SCN) / neonatal intensive care unit (NICU) – baby 9 Admitted patient election status – mother 10 Anaesthesia for operative delivery – indicator 11 Anaesthesia for operative delivery – type 12 Analgesia for labour – indicator 14 Analgesia for labour – type 15 Apgar score at one minute 17 Apgar score at five minutes 18 Artificial reproductive technology – indicator 19 Birth order 20 Birth plurality 21 Birth presentation 22 Birth status 24 Birth weight 25 Blood product transfusion – mother 26 Breastfeeding attempted 27 Collection identifier 29 Congenital anomalies – ICD-10-AM code 30 Congenital anomalies – indicator 31 Country of birth 32 Data submission identifier 34 Date of admission – mother 35 Date of birth – baby 36 Date of birth – mother 37 Date of completion of last pregnancy 38 Date of onset of labour 39 Date of onset of second stage of labour 40 Date of rupture of membranes 42 Page 2 Victorian Perinatal Data Collection manual, version 6.0 Discipline of antenatal care provider 44 Discipline of lead intrapartum care provider 45 Episiotomy – indicator 47 Episode Identifier 48 Estimated blood loss (ml) 49 Estimated date of confinement 50 Estimated gestational age 51 Events of labour and birth – free text 52 Events of labour and birth – ICD-10-AM code 53 Fetal monitoring in labour 54 Fetal monitoring prior to birth – not in labour 56 First given name – mother 58 Formula given in hospital 59 Gestational age at first antenatal visit 60 Gravidity 62 Head circumference - baby 63 Height – self-reported – mother 64 Hepatitis B vaccine received 65 Hospital code (agency identifier) 66 Indication for induction – free text 67 Indication for induction – ICD-10-AM code 68 Indications for operative delivery – free text 69 Indications for operative delivery – ICD-10-AM code 70 Indigenous status – baby 71 Indigenous status – mother 73 Influenza vaccination status 75 Labour induction/augmentation agent 76 Labour induction/augmentation agent – other specified description 77 Labour type 78 Last birth – caesarean section indicator 80 Last feed before discharge taken exclusively from the breast 81 Manual removal of placenta 83 Marital status 84 Maternal medical conditions – free text 85 Page 3 Victorian Perinatal Data Collection manual, version 6.0 Maternal medical conditions – ICD-10-AM code 86 Maternal smoking at less than 20 weeks 88 Maternal smoking at more than or equal to 20 weeks 89 Method of birth 91 Middle name – mother 93 Name of software 94 Neonatal morbidity – free text 95 Neonatal morbidity – ICD-10-AM code 97 Number of antenatal care visits 99 Number of records following 101 Obstetric complications – free text 102 Obstetric complications – ICD-10-AM code 103 Outcome of last pregnancy 105 Parity 107 Patient identifier – baby 108 Patient identifier – mother 109 Perineal/genital laceration – degree/type 110 Perineal laceration – indicator 112 Perineal laceration – repair 113 Pertussis (whooping cough) vaccination status 114 Plan for vaginal birth after caesarean 115 Postpartum complications – free text 116 Postpartum complications – ICD-10-AM code 117 Procedure – ACHI code 118 Procedure – free text 120 Prophylactic oxytocin in third stage 121 Reason for transfer out - baby 122 Reason for transfer out - mother 124 Residential locality 126 Residential postcode 127 Residential road name – mother 128 Residential road number – mother 129 Residential road suffix code – mother 130 Residential road type – mother 131 Page 4 Victorian Perinatal Data Collection manual, version 6.0 Resuscitation method – drugs 132 Resuscitation method – mechanical 133 Separation date – baby 135 Separation date – mother 137 Separation status – baby 138 Separation status – mother 139 Setting of birth – change of intent 140 Setting of birth – change of intent – reason 142 Setting of birth – actual 144 Setting of birth – actual – other specified description 146 Setting of birth – intended 147 Setting of birth – intended – other specified description 149 Sex – baby 150 Spoken English Proficiency 151 Submission number 152 Surname / family name – mother 153 Time of birth 154 Time of onset of labour 155 Time of onset of second stage of labour 156 Time of rupture of membranes 158 Time to established respiration 160 Total number of previous abortions – induced 162 Total number of previous abortions – spontaneous 163 Total number of previous caesareans 164 Total number of previous ectopic pregnancies 165 Total number of previous live births 166 Total number of previous neonatal deaths 167 Total number of previous stillbirths (fetal deaths) 168 Total number of previous unknown outcomes of pregnancy 169 Transaction type flag 170 Transfer destination – baby 171 Transfer destination – mother 172 Version identifier 173 Weight – self-reported – mother 174 Page 5 Victorian Perinatal Data Collection manual, version 6.0 Year of arrival in Australia 175 Page 6 Victorian Perinatal Data Collection manual, version 6.0 Introduction This section provides the specifications for each Victorian Perinatal Data Collection (VPDC) data element collected and reported to the department. The format for the transmission of VPDC data is specified in Section 5: Compilation and submission. Software vendors should read Section 3: Data definitions and Section 5: Compilation and submission together (along with other sections of this manual) to understand the VPDC and transmission requirements. Additional items are derived from the items reported in the VPDC. These are referenced in Section 2: Concept and derived item definitions, for information only. Page 7 Victorian Perinatal Data Collection manual, version 6.0 Admission to high dependency unit (HDU) / intensive care unit (ICU) – mother Specification Definition Whether the mother is admitted into a high dependency unit (HDU) / intensive care unit (ICU) Representation Code Data type Number class Format N Field size 1 Location Episode record Position 94 Permissible values Code Descriptor 1 Admitted to high dependency unit / intensive care unit 2 Not admitted to high dependency unit / intensive care unit 9 Not stated / inadequately described Reporting guide Depending on the facilities, and policies of the hospital, this high dependency care may take place in the labour ward, high dependency unit, intensive care unit, coronary care unit, or any other specialist unit. The mother may spend time in this unit for days either before and/or after the birth. Reported by All Victorian hospitals where a birth has occurred (including birth centres) and homebirth practitioners Reported for All birth episodes Related concepts High dependency unit (HDU), intensive care unit (ICU) (Section 2): Related data items None specified (this section): Related business Admission to high dependency unit (HDU) / intensive care unit rules (Section 4): (ICU) – mother conditionally mandatory data items, Mandatory to report data items Administration Principal data users Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM) Definition source DHHS Version 1. January 1999 Codeset source DHHS Collection start date 1999 Page 8 Victorian Perinatal Data Collection manual, version 6.0 Admission to special care nursery (SCN) / neonatal intensive care unit (NICU) – baby Specification Definition Whether the neonate is admitted into a special care nursery (SCN) or neonatal intensive care unit (NICU) Representation Code Data type Number class Format N Field size 1 Location Episode record Position 113 Permissible values Code Descriptor 1 Admitted to SCN 2 Admitted to NICU 3 Not admitted to SCN or NICU 9 Not stated / inadequately described Reporting guide The criteria for admissions to SCN may vary depending on the facilities available and level of care provided within a particular hospital. This data element is a flag for neonatal morbidity and/or congenital anomalies. If code 1, Admitted to SCN or code 2, Admitted to NICU is selected, then morbidity and/or anomalies must be documented. If the neonate is admitted to both SCN and NICU, report code 2 Admitted to NICU. Do not report a value for stillbirth episodes, leave blank. Reported by All Victorian hospitals where a birth has occurred (including birth centres) and homebirth practitioners Reported for All live birth episodes Related concepts Intensive care unit (ICU) (Section 2): Related data items Congenital anomalies – free text, Hospital code (agency (this Section): identifier), Neonatal morbidity – free text, Neonatal morbidity – ICD-10-AM code Related business Admission