NQF Measure Steward

NQF Measure Steward

NQF Endorsed Measure #0470: Incidence of Episiotomy

In 2008, NPIC partnered with Matthew Hoffman, MD, Chair of Obstetrics and Gynecology, and Linda Daniel, RN, MSN, Director of Performance Improvement and Care Management for the Women’s & Children’s Service Line at Christiana Care Health Services (Newark, DE) to submit the Incidence of Episiotomy to the National Quality Forum for measure endorsement.

Measure Type: Process

Level of Analysis: Facility

Setting of Care: Hospital/Acute Care Facility

Data Source: Administrative claims, paper medical records

Measure Description: Percentage of vaginal deliveries (excluding those coded with shoulder dystocia) during which an episiotomy is performed

Measure Definition
Numerator Number of episiotomy procedures performed (ICD-9 codes 72.1, 72.21, 72.31, 72.71, 73.6; ICD-10 code 0W8NXZZ)
Denominator Total number of vaginal deliveries (MS-DRGs 768, 796, 797, 798, 805, 806, 807 – effective for discharges beginning 10/1/2018)
Exclusion Deliveries coded with shoulder dystocia (ICD-9 code 660.41; ICD-10 code O66.0)
Renewed: June 30, 2021; April 2, 2012
Initial Endorsement: October 24, 2008
For references and scientific acceptability, download the full Measure.