Perinatal DSS 2015-16 Metadata Online Registry (METeOR)

Description

Birth event—additional indication for caesarean section, code N[N] Obligation Conditional, Maximum occurences: 2 Identifying and definitional attributes Short name: Additional indication for caesarean section METeOR identifier: 587048 Registration status: Health, Standard 13/11/2014 Definition: A secondary indication for a caesarean section being performed during a birth event, as represented by a code. Data Element Concept: Birth event—additional indication for caesarean section Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N[N] Maximum character length: 2 Permissible values: Value Meaning 1 Fetal compromise 2 Suspected fetal macrosomia 3 Malpresentation 10 Lack of progress; less than or equal to 3 cm cervical dilatation 11 Lack of progress in the first stage; greater than 3 cm to less than 10 cm cervical dilatation 12 Lack of progress in the second stage 13 Placenta praevia 14 Placental abruption 15 Vasa praevia 16 Antepartum/intrapartum haemorrhage 17 Multiple pregnancy 18 Unsuccessful attempt at assisted delivery 19 Cord prolapse 20 Previous adverse perinatal outcome 21 Previous caesarean section 22 Previous severe perineal trauma 23 Previous shoulder dystocia 29 Other obstetric, medical, surgical, psychological indications 30 Maternal choice in the absence of any obstetric, medical, surgical, psychological indications Supplementary values: 99 Not stated/inadequately described Collection and usage attributes Guide for use: CODE 1 Fetal compromise This includes suspected or actual fetal compromise and intra uterine growth restriction (IUGR). CODE 10 Lack of progress; less than or equal to 3 cm cervical dilatation Lack of progress includes slow or no progress. This code may be appropriate for cases of unsuccessful induction. CODE 11 Lack of progress in the first stage; greater than 3 cm to less than 10 cm cervical dilatation Lack of progress includes slow or no progress. CODE 12 Lack of progress in the second stage Lack of progress includes slow or no progress. CODE 13 Placenta praevia Record placenta praevia as the indication for caesarean section if there is ultrasound or clinical evidence that the edge of the placenta covers the internal cervical os, or encroaches into the lower segment less than 2 cm away from the internal cervical os. CODE 14 Placental abruption Record placental abruption as the indication for caesarean section if there is ultrasound or clinical evidence antenatally of abruption of the placenta prior to onset or during labour. CODE 15 Vasa praevia Record vasa praevia as the indication for caesarean section if there is ultrasound or visual evidence of exposed fetal blood vessels running across the fetal membrane below or at the level of the fetal presenting part in the lower segment of the uterus. This code is to be used when the caesarean section is planned or in the case of an emergency when the vessels may have ruptured. CODE 16 Antepartum/intrapartum haemorrhage Record antepartum/intrapartum haemorrhage as the indication for caesarean section if there has been any antenatal or intrapartum vaginal bleeding that leads to the immediate delivery of the baby by caesarean section. This code should only be used as a main indication if a more specific cause of the antepartum/intrapartum haemorrhage is not known. Where there is a vasa praevia and an antepartum/intrapartum haemorrhage, Code 15 is to be recorded as the main indication and Code 16 as an additional indication. CODE 22 Previous severe perineal trauma Includes previous 4th degree tears and other perineal damage or injury where a woman is symptomatic and the clinician determines the caesarean section is justified. CODE 29 Other obstetric, medical, surgical, psychological indications Where a woman has a psychopathological indication for caesarean section, e.g. extreme fear of natural childbirth, this code should be used. It is not to be used for psychosocial indications which should be coded under Code 30. CODE 30 Maternal choice in the absence of any obstetric, medical, surgical, psychological indications This includes psychosocial indications. Source and reference attributes Submitting organisation: National Perinatal Data Development Committee Data set specification specific attributes Perinatal DSS 2015-16 Conditional obligation: This data element is to be recorded if the response to Birth event—birth method, code N is Code 4, Caesarean section. This is also conditional on Birth event—main indication for caesarean section, code N[N] being completed. Data element attributes Collection and usage attributes Collection methods: Additional indications for caesarean section are conditional on there being more than one reason for which a caesarean was performed. Additional indications for caesarean section are completed after the Birth event—main indication for caesarean section, code N[N] has been identified. Multiple codes can be selected. Up to two additional indications can be recorded as contributing to the need for a caesarean section. However Code 30 should not be used in conjunction with any other code. Source and reference attributes Submitting organisation: National Perinatal Data Development Committee Relational attributes Related metadata references: Supersedes Birth event—additional indications for caesarean section, code NN Health, Superseded 13/11/2014 See also Birth event—birth method, code N Health, Standard 06/09/2006 See also Birth event—main indication for caesarean section, code N[N] Health, Standard 13/11/2014 Implementation in Data Set Specifications: Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

integer

Description

Birth event—additional indication for induction of labour, code N[N] Obligation Conditional, Maximum occurences: 2 Identifying and definitional attributes Short name: Additional indication for induction of labour METeOR identifier: 573654 Registration status: Health, Standard 13/11/2014 Definition: A secondary indication for an induction being performed to commence a birth event, as represented by a code. Data Element Concept: Birth event—additional indication for induction of labour Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N[N] Maximum character length: 2 Permissible values: Value Meaning 1 Prolonged pregnancy 2 Prelabour rupture of membranes 3 Diabetes 4 Hypertensive disorders 5 Multiple pregnancy 6 Chorioamnionitis (includes suspected) 7 Cholestasis of pregnancy 8 Antepartum haemorrhage 9 Maternal age 10 Body Mass Index (BMI) 11 Maternal mental health indication 12 Previous adverse perinatal outcome 19 Other maternal obstetric or medical indication 20 Fetal compromise (includes suspected) 21 Fetal growth restriction (includes suspected) 22 Fetal macrosomia (includes suspected) 23 Fetal death 24 Fetal congenital anomaly 80 Administrative or geographical indication 81 Maternal choice in the absence of any obstetric, medical, fetal, administrative or geographical indication 89 Other indication not elsewhere classified Supplementary values: 99 Not stated/inadequately described Collection and usage attributes Guide for use: Indications are grouped into Maternal indications (Codes 1 to 19); Fetal indications (Codes 20 to 39) and Other indications (Codes 80-89). CODE 1 Prolonged pregnancy While prolonged pregnancy is commonly defined as greater than or equal to 41 weeks, in some circumstances a clinician may recommend inducing a woman earlier than this. Such circumstances include advanced maternal age which may elevate the degree of risk (Haavaldsen et al 2010). Other special circumstances may apply (see, for example, Yao et al 2014; Drysdale et al 2012). With appropriate professional judgement, these cases may be coded under Code 1, Prolonged pregnancy. Consideration could be given to coding maternal age (Code 9) and other specific indications as additional indications where applicable. CODE 2 Prelabour rupture of membranes Can refer to preterm or term spontaneous rupture of membranes, occurs before labour has commenced, and may be prolonged. CODE 4 Hypertensive disorders Includes chronic (essential and secondary) and gestational hypertensive disorders, preeclampsia and HELLP syndrome (HELLP stands for Haemolysis, Elevated Liver enzymes, Low Platelet count). CODE 10 Body Mass Index (BMI) May refer to low or high BMI. CODE 11 Maternal mental health indication Refers to diagnosed mental health disorders and conditions. CODE 12 Previous adverse perinatal outcome A woman who experienced a previous late unexplained stillbirth or other adverse perinatal outcome may wish to be induced. CODE 19 Other maternal obstetric or medical indication Examples include renal disease, abnormal liver function tests, cardiac disease, Deep Vein Thrombosis (DVT), antiphospholipid syndrome, chronic back pain, dental infections, gestational thrombocytopenia, Lupus, hip dysplasia, history of pulmonary embolism etc. Note that diagnosed maternal mental health disorders and conditions should be coded under Code 11, Maternal mental health indication. CODE 20 Fetal compromise (includes suspected) Includes oligohydramnios, reduced fetal movement, abnormal antenatal cardiotocography (CTG), abnormal Doppler, other abnormalities of fetal wellbeing (e.g. abnormal profile). CODE 21 Fetal growth restriction (includes suspected) It is not always possible to determine fetal growth restriction (also known as intra uterine growth restriction (IUGR)) until the baby is born therefore this code is for actual or suspected fetal growth restriction. CODE 80 Administrative or geographical indication Examples include: to fit with a caregiver's schedule, to ensure availability of theatre, anaesthetist or other staffing reasons. This code could also be used where a pregnant woman is normally resident in a rural or remote area or an area without adequate birthing facilities and the need for induction is determined by such factors as the available facilities and the woman's ability and availability to travel to a centre with suitable facilities. CODE 81 Maternal choice in the absence of any obstetric, medical, fetal, administrative or geographical indication Note that Code 81 is not to be used in conjunction with additional indications. Code 81 should be used where the woman has requested an induction and none of the other permissible values, including Code 89, apply. It is important to distinguish between a woman’s choice, and other indications such as maternal medical/obstetric, fetal and administrative/geographical reasons for induction. Where the clinician determines that a diagnosed maternal mental health indication is the reason for the induction, Code 11 should be selected. Code 80 should also be considered for relevance as per the examples provided in the Guide for use for that code. These codes may be selected as main or additional indications. CODE 89 Other indication not elsewhere classified Includes other fetal indications such as fetal anaemia and isoimmunisation; and other indications not coded under any other permissible value in the list of indications. Do not code maternal choice (see Guide for use information above) here—use Code 81. Source and reference attributes Reference documents: Drysdale H, Ranasinha S, Kendall A, Knight M, Wallace EM Ethnicity and the risk of late-pregnancy stillbirth. Medical Journal of Australia. 2012 Sep 3;197 (5): 278-81. Haavaldsen C, Sarfraz AA, Samuelsen SO, Eskild A. The impact of maternal age on fetal death: does length of gestation matter? American Journal of Obstetrics & Gynecology. 2010 Dec; 203(6): 554.e1-8. Yao R1, Ananth CV, Park BY, Pereira L, Plante LA; Perinatal Research Consortium. Obesity and the risk of stillbirth: a population-based cohort study. American Journal of Obstetrics & Gynecology. 2014 May; 210 (5):457.e1-9. Data set specification specific attributes Perinatal DSS 2015-16 Conditional obligation: This data element is to be recorded if the response to Birth event—labour onset type, code N is Code 2, Induced. This is also conditional on Birth event—main indication for induction of labour, code N[N] being completed. Data element attributes Collection and usage attributes Guide for use: Additional indications for induction are conditional on there being more than one reason for which an induction was performed. Additional indications for induction are completed after the Birth event—main indication for induction, code N[N] has been identified. Multiple codes can be selected. Up to two additional indications can be recorded as contributing to the need for induction. However Code 81 should not be used in conjunction with any other code. Source and reference attributes Submitting organisation: National Perinatal Data Development Committee Relational attributes Related metadata references: See also Birth event—main indication for induction of labour, code N[N] Health, Standard 13/11/2014 Implementation in Data Set Specifications: Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

integer

Description

Birth event—main indication for caesarean section, code N[N] Obligation Conditional Identifying and definitional attributes Short name: Main indication for caesarean section METeOR identifier: 587046 Registration status: Health, Standard 13/11/2014 Definition: The primary indication for a caesarean section being performed during a birth event, as represented by a code. Data Element Concept: Birth event—main indication for caesarean section Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N[N] Maximum character length: 2 Permissible values: Value Meaning 1 Fetal compromise 2 Suspected fetal macrosomia 3 Malpresentation 10 Lack of progress; less than or equal to 3 cm cervical dilatation 11 Lack of progress in the first stage; greater than 3 cm to less than 10 cm cervical dilatation 12 Lack of progress in the second stage 13 Placenta praevia 14 Placental abruption 15 Vasa praevia 16 Antepartum/intrapartum haemorrhage 17 Multiple pregnancy 18 Unsuccessful attempt at assisted delivery 19 Cord prolapse 20 Previous adverse perinatal outcome 21 Previous caesarean section 22 Previous severe perineal trauma 23 Previous shoulder dystocia 29 Other obstetric, medical, surgical, psychological indications 30 Maternal choice in the absence of any obstetric, medical, surgical, psychological indications Supplementary values: 99 Not stated/inadequately described Collection and usage attributes Guide for use: CODE 1 Fetal compromise This includes suspected or actual fetal compromise and intra uterine growth restriction (IUGR). CODE 10 Lack of progress; less than or equal to 3 cm cervical dilatation Lack of progress includes slow or no progress. This code may be appropriate for cases of unsuccessful induction. CODE 11 Lack of progress in the first stage; greater than 3 cm to less than 10 cm cervical dilatation Lack of progress includes slow or no progress. CODE 12 Lack of progress in the second stage Lack of progress includes slow or no progress. CODE 13 Placenta praevia Record placenta praevia as the indication for caesarean section if there is ultrasound or clinical evidence that the edge of the placenta covers the internal cervical os, or encroaches into the lower segment less than 2 cm away from the internal cervical os. CODE 14 Placental abruption Record placental abruption as the indication for caesarean section if there is ultrasound or clinical evidence antenatally of abruption of the placenta prior to onset or during labour. CODE 15 Vasa praevia Record vasa praevia as the indication for caesarean section if there is ultrasound or visual evidence of exposed fetal blood vessels running across the fetal membrane below or at the level of the fetal presenting part in the lower segment of the uterus. This code is to be used when the caesarean section is planned or in the case of an emergency when the vessels may have ruptured. CODE 16 Antepartum/intrapartum haemorrhage Record antepartum/intrapartum haemorrhage as the indication for caesarean section if there has been any antenatal or intrapartum vaginal bleeding that leads to the immediate delivery of the baby by caesarean section. This code should only be used as a main indication if a more specific cause of the antepartum/intrapartum haemorrhage is not known. Where there is a vasa praevia and an antepartum/intrapartum haemorrhage, Code 15 is to be recorded as the main indication and Code 16 as an additional indication. CODE 22 Previous severe perineal trauma Includes previous 4th degree tears and other perineal damage or injury where a woman is symptomatic and the clinician determines the caesarean section is justified. CODE 29 Other obstetric, medical, surgical, psychological indications Where a woman has a psychopathological indication for caesarean section, e.g. extreme fear of natural childbirth, this code should be used. It is not to be used for psychosocial indications which should be coded under Code 30. CODE 30 Maternal choice in the absence of any obstetric, medical, surgical, psychological indications This includes psychosocial indications. Source and reference attributes Submitting organisation: National Perinatal Data Development Committee Data set specification specific attributes Perinatal DSS 2015-16 Conditional obligation: This data element is to be recorded if the response to Birth event—birth method, code N is Code 4, Caesarean section. Data element attributes Collection and usage attributes Guide for use: This data element records the main indication for performing a caesarean section. Only one code may be selected. Collection methods: The main indication should be the indication that the clinician attending the birth believes to be the primary reason for the caesarean section being performed. It should be determined at the time of delivery and not revised later or selected based on information that becomes available after delivery such as results of tests or procedures. Source and reference attributes Submitting organisation: National Perinatal Data Development Committee Relational attributes Related metadata references: See also Birth event—additional indication for caesarean section, code N[N] Health, Standard 13/11/2014 See also Birth event—birth method, code N Health, Standard 06/09/2006 Supersedes Birth event—main indication for caesarean section, code NN Health, Superseded 13/11/2014 Implementation in Data Set Specifications: Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

integer

Description

Birth event—main indication for induction of labour, code N[N] Obligation Conditional Identifying and definitional attributes Short name: Main indication for induction of labour METeOR identifier: 569595 Registration status: Health, Standard 13/11/2014 Definition: The primary indication for an induction being performed to commence a birth event, as represented by a code. Data Element Concept: Birth event—main indication for induction of labour Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N[N] Maximum character length: 2 Permissible values: Value Meaning 1 Prolonged pregnancy 2 Prelabour rupture of membranes 3 Diabetes 4 Hypertensive disorders 5 Multiple pregnancy 6 Chorioamnionitis (includes suspected) 7 Cholestasis of pregnancy 8 Antepartum haemorrhage 9 Maternal age 10 Body Mass Index (BMI) 11 Maternal mental health indication 12 Previous adverse perinatal outcome 19 Other maternal obstetric or medical indication 20 Fetal compromise (includes suspected) 21 Fetal growth restriction (includes suspected) 22 Fetal macrosomia (includes suspected) 23 Fetal death 24 Fetal congenital anomaly 80 Administrative or geographical indication 81 Maternal choice in the absence of any obstetric, medical, fetal, administrative or geographical indication 89 Other indication not elsewhere classified Supplementary values: 99 Not stated/inadequately described Collection and usage attributes Guide for use: Indications are grouped into Maternal indications (Codes 1 to 19); Fetal indications (Codes 20 to 39) and Other indications (Codes 80-89). CODE 1 Prolonged pregnancy While prolonged pregnancy is commonly defined as greater than or equal to 41 weeks, in some circumstances a clinician may recommend inducing a woman earlier than this. Such circumstances include advanced maternal age which may elevate the degree of risk (Haavaldsen et al 2010). Other special circumstances may apply (see, for example, Yao et al 2014; Drysdale et al 2012). With appropriate professional judgement, these cases may be coded under Code 1, Prolonged pregnancy. Consideration could be given to coding maternal age (Code 9) and other specific indications as additional indications where applicable. CODE 2 Prelabour rupture of membranes Can refer to preterm or term spontaneous rupture of membranes, occurs before labour has commenced, and may be prolonged. CODE 4 Hypertensive disorders Includes chronic (essential and secondary) and gestational hypertensive disorders, preeclampsia and HELLP syndrome (HELLP stands for Haemolysis, Elevated Liver enzymes, Low Platelet count). CODE 10 Body Mass Index (BMI) May refer to low or high BMI. CODE 11 Maternal mental health indication Refers to diagnosed mental health disorders and conditions. CODE 12 Previous adverse perinatal outcome A woman who experienced a previous late unexplained stillbirth or other adverse perinatal outcome may wish to be induced. CODE 19 Other maternal obstetric or medical indication Examples include renal disease, abnormal liver function tests, cardiac disease, Deep Vein Thrombosis (DVT), antiphospholipid syndrome, chronic back pain, dental infections, gestational thrombocytopenia, Lupus, hip dysplasia, history of pulmonary embolism etc. Note that diagnosed maternal mental health disorders and conditions should be coded under Code 11, Maternal mental health indication. CODE 20 Fetal compromise (includes suspected) Includes oligohydramnios, reduced fetal movement, abnormal antenatal cardiotocography (CTG), abnormal Doppler, other abnormalities of fetal wellbeing (e.g. abnormal profile). CODE 21 Fetal growth restriction (includes suspected) It is not always possible to determine fetal growth restriction (also known as intra uterine growth restriction (IUGR)) until the baby is born therefore this code is for actual or suspected fetal growth restriction. CODE 80 Administrative or geographical indication Examples include: to fit with a caregiver's schedule, to ensure availability of theatre, anaesthetist or other staffing reasons. This code could also be used where a pregnant woman is normally resident in a rural or remote area or an area without adequate birthing facilities and the need for induction is determined by such factors as the available facilities and the woman's ability and availability to travel to a centre with suitable facilities. CODE 81 Maternal choice in the absence of any obstetric, medical, fetal, administrative or geographical indication Note that Code 81 is not to be used in conjunction with additional indications. Code 81 should be used where the woman has requested an induction and none of the other permissible values, including Code 89, apply. It is important to distinguish between a woman’s choice, and other indications such as maternal medical/obstetric, fetal and administrative/geographical reasons for induction. Where the clinician determines that a diagnosed maternal mental health indication is the reason for the induction, Code 11 should be selected. Code 80 should also be considered for relevance as per the examples provided in the Guide for use for that code. These codes may be selected as main or additional indications. CODE 89 Other indication not elsewhere classified Includes other fetal indications such as fetal anaemia and isoimmunisation; and other indications not coded under any other permissible value in the list of indications. Do not code maternal choice (see Guide for use information above) here—use Code 81. Source and reference attributes Reference documents: Drysdale H, Ranasinha S, Kendall A, Knight M, Wallace EM Ethnicity and the risk of late-pregnancy stillbirth. Medical Journal of Australia. 2012 Sep 3;197 (5): 278-81. Haavaldsen C, Sarfraz AA, Samuelsen SO, Eskild A. The impact of maternal age on fetal death: does length of gestation matter? American Journal of Obstetrics & Gynecology. 2010 Dec; 203(6): 554.e1-8. Yao R1, Ananth CV, Park BY, Pereira L, Plante LA; Perinatal Research Consortium. Obesity and the risk of stillbirth: a population-based cohort study. American Journal of Obstetrics & Gynecology. 2014 May; 210 (5):457.e1-9. Data set specification specific attributes Perinatal DSS 2015-16 Conditional obligation: This data element is to be recorded if the response to Birth event—labour onset type, code N is Code 2, Induced. Data element attributes Collection and usage attributes Guide for use: This data element records the main indication for induction. Only one code may be selected. Collection methods: Indications for induction are conditional on an induction being performed. Indications for induction are completed after the Birth event—labour onset type, code N has been coded as: 2 Induced. Up to 2 additional codes may be selected using data element Birth event—additional indication for induction of labour, code N[N] which is conditional on a main indication being selected. Source and reference attributes Submitting organisation: National Perinatal Data Development Committee Relational attributes Related metadata references: See also Birth event—additional indication for induction of labour, code N[N] Health, Standard 13/11/2014 See also Birth event—labour onset type, code N Health, Standard 07/03/2014 Implementation in Data Set Specifications: Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

integer

Description

Female—blood transfusion due to primary postpartum haemorrhage indicator, yes/no/not stated/inadequately described code N Obligation Conditional Identifying and definitional attributes Short name: Blood transfusion for primary PPH METeOR identifier: 522211 Registration status: Health, Standard 07/03/2014 Definition: An indicator of whether a female received a blood transfusion as a result of a primary postpartum haemorrhage, as represented by a code. Data Element Concept: Female—blood transfusion due to primary postpartum haemorrhage indicator Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Yes 2 No Supplementary values: 9 Not stated/inadequately described Collection and usage attributes Guide for use: CODE 9 Not stated/inadequately described This code is not for use in primary data collections. Data set specification specific attributes Perinatal DSS 2015-16 Conditional obligation: This data element is conditional on Female—primary postpartum haemorrhage indicator, yes/no/not stated/inadequately described code N being coded to Yes. Data element attributes Collection and usage attributes Guide for use: Blood transfusion refers to the administration (including autologous blood via a cell salvage procedure), of blood, blood products or blood substitutes, but excludes volume expanders. CODE 1 Yes To be reported if the woman received a blood transfusion. CODE 2 No To be reported if a woman did not receive a blood transfusion (including cases where one is offered but refused). CODE 9 Not stated/inadequately described To be recorded by data entry personnel (state/territory health authority) if the data field is left blank or is inadequately completed in the perinatal data collection form or extract. Clinicians should not record code 9. Source and reference attributes Submitting organisation: National Perinatal Data Development Committee Relational attributes Related metadata references: See also Female—estimated blood loss indicating primary postpartum haemorrhage, estimated blood loss volume category, code N Health, Standard 07/03/2014 See also Female—primary postpartum haemorrhage indicator, yes/no/not stated/inadequately described code N Health, Standard 07/03/2014 Implementation in Data Set Specifications: Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

integer

Description

Female—diabetes mellitus during pregnancy indicator, yes/no/not stated/inadequately described code N Identifying and definitional attributes Short name: Diabetes during pregnancy METeOR identifier: 504291 Registration status: Health, Standard 07/03/2014 Definition: An indicator of whether a female has diabetes mellitus during pregnancy, based on a current or previous diagnosis, as represented by a code. Data Element Concept: Female—diabetes mellitus during pregnancy indicator Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Yes 2 No Supplementary values: 9 Not stated/inadequately described Collection and usage attributes Guide for use: CODE 9 Not stated/inadequately described This code is not for use in primary data collections. Data set specification specific attributes Perinatal DSS 2015-16 DSS specific information: It is acceptable for jurisdictions to report only Code 1, Yes and Code 9, Not stated/inadequately described against this item. Data element attributes Collection and usage attributes Guide for use: CODE 1 Yes To be reported if the woman has pre-existing, gestational or other diabetes during this pregnancy. CODE 2 No To be reported if the woman does not have any form of diabetes during this pregnancy. CODE 9 Not stated/inadequately described To be recorded by data entry personnel (state/territory health authority) if the data field is left blank or is inadequately completed in the perinatal data collection form or extract. Clinicians should not record code 9. Collection methods: The diagnosis is preferably derived from, and substantiated by clinical documentation, which would be reviewed at the time of delivery. However, this information may not be available, in which case the patient may self-report to the clinician that they have been diagnosed with diabetes mellitus. Source and reference attributes Submitting organisation: National Perinatal Data Development Committee Relational attributes Related metadata references: See also Female—type of diabetes mellitus during pregnancy, code N Health, Standard 07/03/2014 See also Female—type of diabetes mellitus therapy during pregnancy, code N Health, Standard 07/03/2014 Implementation in Data Set Specifications: Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

integer

Description

Female—estimated blood loss indicating primary postpartum haemorrhage, estimated blood loss volume category, code N Obligation Conditional Identifying and definitional attributes Short name: PPH blood loss METeOR identifier: 522192 Registration status: Health, Standard 07/03/2014 Definition: The estimated amount of blood lost by a female postpartum indicating the occurrence of primary postpartum haemorrhage, as represented by a code set. Data Element Concept: Female—estimated blood loss indicating primary postpartum haemorrhage Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 500–999 mls 2 1000–1499 mls 3 1500 mls or more Supplementary values: 9 Not stated/inadequately described Proposed unit of measure: millilitre (ml) Source and reference attributes Submitting organisation: National Perinatal Data Development Committee Data set specification specific attributes Perinatal DSS 2015-16 Conditional obligation: This data element is conditional on Female—primary postpartum haemorrhage indicator, yes/no/not stated/inadequately described code N being coded to Yes. Data element attributes Relational attributes Related metadata references: See also Female—blood transfusion due to primary postpartum haemorrhage indicator, yes/no/not stated/inadequately described code N Health, Standard 07/03/2014 See also Female—primary postpartum haemorrhage indicator, yes/no/not stated/inadequately described code N Health, Standard 07/03/2014 Implementation in Data Set Specifications: Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

integer

Description

Female—hypertensive disorder during pregnancy indicator, yes/no/not stated/inadequately described code N Identifying and definitional attributes Short name: Hypertension during pregnancy METeOR identifier: 516807 Registration status: Health, Standard 07/03/2014 Definition: An indicator of whether a female has a hypertensive disorder during pregnancy, based on a current or previous diagnosis, as represented by a code. Data Element Concept: Female—hypertensive disorder during pregnancy indicator Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Yes 2 No Supplementary values: 9 Not stated/inadequately described Collection and usage attributes Guide for use: CODE 9 Not stated/inadequately described This code is not for use in primary data collections. Data set specification specific attributes Perinatal DSS 2015-16 DSS specific information: It is acceptable for jurisdictions to report only Code 1, Yes and Code 9, Not stated/inadequately described against this item. Data element attributes Collection and usage attributes Guide for use: CODE 1 Yes To be reported if the woman has a hypertensive disorder during this pregnancy, including where a woman’s hypertensive disorder is controlled through treatment during this pregnancy. CODE 2 No To be reported if the woman does not have a hypertensive disorder during this pregnancy. CODE 9 Not stated/inadequately described To be recorded by data entry personnel (state/territory health authority) if the data field is left blank or is inadequately completed in the perinatal data collection form or extract. Clinicians should not record code 9. Collection methods: Based on SOMANZ Guidelines 2008, normal pregnancy is characterised by a fall in blood pressure, detectable in the first trimester and usually reaching a nadir in the second trimester. Blood pressure rises towards pre-conception levels towards the end of the third trimester. 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. Measurements should be confirmed by repeated readings over several hours. The diagnosis is preferably derived from and substantiated by clinical documentation which should be reviewed at the time of delivery. However this information may not be available in which case the patient may self-report to the clinician that they have been diagnosed with a hypertensive disorder. Source and reference attributes Submitting organisation: National Perinatal Data Development Committee Reference documents: Lowe SA, Brown MA, Dekker G, Gatt S, McLintock C, McMahon L et al. 2008. Guidelines for the Management of Hypertension in Pregnancy. Society of Obstetric Medicine of Australia and New Zealand Relational attributes Related metadata references: See also Female—type of hypertensive disorder during pregnancy, code N Health, Standard 07/03/2014 Implementation in Data Set Specifications: Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

integer

Description

Female—primary postpartum haemorrhage indicator, yes/no/not stated/inadequately described code N Identifying and definitional attributes Short name: Primary postpartum haemorrhage indicator METeOR identifier: 504959 Registration status: Health, Standard 07/03/2014 Definition: An indicator of whether a female who has given birth experienced a primary postpartum haemorrhage, as represented by a code. Data Element Concept: Female—primary postpartum haemorrhage indicator Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Yes 2 No Supplementary values: 9 Not stated/inadequately described Collection and usage attributes Guide for use: CODE 9 Not stated/inadequately described This code is not for use in primary data collections. Data element attributes Collection and usage attributes Guide for use: CODE 1 Yes To be reported if the woman experienced a primary postpartum haemorrhage. CODE 2 No To be reported if a woman did not experience a primary postpartum haemorrhage. CODE 9 Not stated/inadequately described To be recorded by data entry personnel (state/territory health authority) if the data field is left blank or is inadequately completed in the perinatal data collection form or extract. Clinicians should not record code 9. Source and reference attributes Submitting organisation: National Perinatal Data Development Committee Relational attributes Related metadata references: See also Female—blood transfusion due to primary postpartum haemorrhage indicator, yes/no/not stated/inadequately described code N Health, Standard 07/03/2014 See also Female—estimated blood loss indicating primary postpartum haemorrhage, estimated blood loss volume category, code N Health, Standard 07/03/2014 Implementation in Data Set Specifications: Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

integer

Description

Female—type of diabetes mellitus during pregnancy, code N Obligation Conditional Identifying and definitional attributes Short name: Diabetes mellitus type during pregnancy METeOR identifier: 516668 Registration status: Health, Standard 07/03/2014 Definition: The type of diabetes mellitus a female has during pregnancy, based on a current or previous diagnosis, as represented by a code. Data Element Concept: Female—type of diabetes mellitus during pregnancy Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Pre-existing Type 1 diabetes 2 Pre-existing Type 2 diabetes 3 Gestational diabetes mellitus (GDM) 8 Other type of diabetes mellitus Supplementary values: 9 Not stated/inadequately described Collection and usage attributes Guide for use: Note that where there is a Gestational diabetes mellitus (GDM) and a current history of Pre-existing Type 2 diabetes then record Code 2 Pre-existing Type 2 diabetes. While most women will know what type of diabetes they have, where their type of diabetes is unknown the clinician should leave the collection form/system blank. This will be coded as a '9' by the data custodian. CODE 1 Pre-existing Type 1 diabetes Beta-cell destruction, usually leading to absolute insulin deficiency. Includes those cases attributed to an autoimmune process, as well as those with beta-cell destruction and who are prone to ketoacidosis for which neither an aetiology nor pathogenesis is known (idiopathic). It does not include those forms of beta-cell destruction or failure to which specific causes can be assigned (e.g. cystic fibrosis, mitochondrial defects). Some subjects with Type 1 diabetes can be identified at earlier clinical stages than 'diabetes mellitus'. CODE 2 Pre-existing Type 2 diabetes Type 2 includes the common major form of diabetes, which results from defect(s) in insulin secretion, almost always with a major contribution from insulin resistance. CODE 3 Gestational diabetes mellitus (GDM) 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 if the condition persists after pregnancy. Diagnosis is to be based on the Australian Diabetes in Pregnancy Society (ADIPS) Guidelines. If the clinician does not have information as to whether these guidelines have been used, available information about diagnosis of GDM is still to be reported. CODE 8 Other type of diabetes mellitus This categorisation include less common causes of diabetes mellitus, but are those in which the underlying defect or disease process can be identified in a relatively specific manner. They include, for example, genetic defects of beta-cell function, genetic defects in insulin action, diseases of the exocrine pancreas, endocrinopathies, drug or chemical-induced, infections, uncommon forms of immune-mediated diabetes, other genetic syndromes sometimes associated with diabetes. Impaired glucose regulation is not to be included here. CODE 9 Not stated/inadequately described To be recorded by data entry personnel (state/territory health authority) if the data field is left blank or is inadequately completed in the perinatal data collection form or extract. Clinicians should not record Code 9. Source and reference attributes Origin: Nankervis A, McIntyre HD, Moses R, Ross GP, Callaway L, Porter C et al. 2013. Australasian Diabetes In Pregnancy Society (ADIPS) Consensus Guidelines for the Testing and Diagnosis of Gestational Diabetes Mellitus in Australia. Australasian Diabetes In Pregnancy Society (ADIPS). Data set specification specific attributes Perinatal DSS 2015-16 Conditional obligation: This data element is conditional on Female—diabetes mellitus during pregnancy indicator, yes/no/not stated/inadequately described code N being coded to Yes. Data element attributes Collection and usage attributes Collection methods: The diagnosis is preferably derived from, and substantiated by, clinical documentation which should be reviewed at the time of delivery. However, this information may not be available, in which case the patient may self-report to the clinician that they have been diagnosed with a particular type of diabetes mellitus. Jurisdictions that record perinatal data using the ICD-10-AM should apply the following codes: 'Code 1 Pre-existing Type 1 diabetes' is equivalent to O24.0 in the ICD-10-AM 'Code 2 Pre-existing Type 2 diabetes' is equivalent to O24.1 in the ICD-10-AM 'Code 3 Gestational diabetes mellitus (GDM)' is equivalent to O24.4 in the ICD-10-AM 'Code 8 Other type of diabetes mellitus' is equivalent to O24.2 in the ICD-10-AM See also related data element Female—type of diabetes therapy in pregnancy, code NN where the following fifth character subdivisions are for use with categories O24.1–O24.9: • 2 Insulin treated • 3 Oral hypoglycaemic therapy • 4 Other: diet, exercise, lifestyle management • 9 Unspecified. Source and reference attributes Submitting organisation: National Perinatal Data Development Committee Reference documents: National Casemix and Classification Centre 2013. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM), Australian Classification of Health Interventions (ACHI) and Australian Coding Standards (ACS), Eighth edition. National Casemix and Classification Centre, Australian Health Services Research Institute: University of Wollongong Relational attributes Related metadata references: See also Female—diabetes mellitus during pregnancy indicator, yes/no/not stated/inadequately described code N Health, Standard 07/03/2014 See also Female—type of diabetes mellitus therapy during pregnancy, code N Health, Standard 07/03/2014 Implementation in Data Set Specifications: Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

integer

Description

Female—type of diabetes mellitus therapy during pregnancy, code N Obligation Conditional, Maximum occurences: 3 Identifying and definitional attributes Short name: Diabetes therapy type during pregnancy METeOR identifier: 516185 Registration status: Health, Standard 07/03/2014 Definition: The type of diabetes mellitus treatment which a female is prescribed during pregnancy, as represented by a code. Data Element Concept: Female—type of diabetes mellitus therapy during pregnancy Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Insulin 2 Oral hypoglycaemic 3 Diet and exercise Supplementary values: 9 Not stated/inadequately described Collection and usage attributes Guide for use: All therapies prescribed during pregnancy should be recorded. Therefore more than one code can be selected when reporting this item. CODE 1 Insulin CODE 2 Oral hypoglycaemic This code includes the options of sulphonylurea, biguanide (e.g. metformin), alpha-glucosidase inhibitor, thiazolidinedione, meglitinide, combination (e.g. biguanide & sulphonylurea), or other. CODE 3 Diet and exercise This code includes the options of generalised prescribed diet; avoid added sugar/simple carbohydrates (CHOs); low joule diet; portion exchange diet and uses glycaemic index and a recommendation for increased exercise. CODE 9 Not stated/inadequately described To be recorded by data entry personnel (state/territory health authority) if the data field is left blank or is inadequately completed in the perinatal data collection form or extract. Clinicians should not record Code 9. Data set specification specific attributes Perinatal DSS 2015-16 Conditional obligation: This data element is conditional on Female—diabetes mellitus during pregnancy indicator, yes/no/not stated/inadequately described code N being coded to Yes. Data element attributes Collection and usage attributes Collection methods: Jurisdictions that record perinatal data using the ICD-10-AM should apply the following codes: 'Code 1 Insulin' is equivalent in the ICD-10-AM to a code in the range O24.1–24.9 used in conjunction with the fifth character '2' (insulin treated). 'Code 2 Oral hypoglycaemic' is equivalent in the ICD-10-AM to a code in the range O24.1–24.9 used in conjunction with the fifth character '3' (oral hypoglycaemic therapy). 'Code 3 Diet and exercise' is equivalent in the ICD-10-AM to a code in the range O24.1–24.9 used in conjunction with the fifth character '4' (other; diet; exercise; lifestyle management). For example, for a mother who has pre-existing Type 2 diabetes mellitus and uses oral hypoglycaemic therapy and insulin, this would be coded in the ICD-10-AM as O2412 and O2413 and would be reported against this data item using Codes 1 and 2. Source and reference attributes Reference documents: National Casemix and Classification Centre 2013. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM), Australian Classification of Health Interventions (ACHI) and Australian Coding Standards (ACS), Eighth edition. National Casemix and Classification Centre, Australian Health Services Research Institute: University of Wollongong Relational attributes Related metadata references: See also Female—diabetes mellitus during pregnancy indicator, yes/no/not stated/inadequately described code N Health, Standard 07/03/2014 See also Female—type of diabetes mellitus during pregnancy, code N Health, Standard 07/03/2014 See also Person—diabetes therapy type, code NN Health, Standard 01/03/2005 Implementation in Data Set Specifications: Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

integer

Description

Female—type of hypertensive disorder during pregnancy, code N Obligation Conditional, Maximum occurences: 3 Identifying and definitional attributes Short name: Hypertension type during pregnancy METeOR identifier: 504548 Registration status: Health, Standard 07/03/2014 Definition: The type of hypertensive disorder during pregnancy which a female has been diagnosed with, as represented by a code. Context: Perinatal statistics Data Element Concept: Female—type of hypertensive disorder during pregnancy Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Eclampsia 2 Preeclampsia 3 Gestational hypertension 4 Chronic hypertension Supplementary values: 9 Not stated/inadequately described Collection and usage attributes Guide for use: More than one code can be selected when reporting on this item. For example, for a woman who has preeclampsia superimposed on chronic hypertension, select both code 2 and code 4. For a woman who develops gestational hypertension which progresses to eclampsia, select codes 1 and 3. CODE 1 Eclampsia Eclampsia is characterised by grand mal seizures, hypertension, proteinuria, oedema and may progress to coma. Before a seizure, a patient may experience a body temperature of over 40°C, anxiety, epigastric pain, severe headache and blurred vision. Complications of eclampsia may include cerebral haemorrhage, pulmonary oedema, renal failure, abruptio placentae and temporary blindness (National Centre for Classification in Health, 2010). CODE 2 Preeclampsia Preeclampsia is a multi-system disorder unique to human pregnancy characterised by hypertension and involvement of one or more other organ systems and/or the fetus. Proteinuria is the most commonly recognised additional feature after hypertension but should not be considered mandatory to make the clinical diagnosis. A diagnosis of preeclampsia can be made when hypertension arises after 20 weeks gestation and is accompanied by one or more of the following: Renal involvement, Haematological involvement, Liver involvement, Neurological involvement, Pulmonary oedema, Fetal growth restriction, Placental abruption. Women with HELLP syndrome (which stands for Haemolysis, Elevated Liver Enzymes, Low Platelet count and is a variant of preeclampsia) are to be included under this code for preeclampsia. CODE 3 Gestational hypertension Gestational hypertension is characterised by the new onset of hypertension after 20 weeks gestation without any maternal or fetal features of preeclampsia, followed by return of blood pressure to normal within 3 months post-partum. CODE 4 Chronic hypertension This may include essential or secondary hypertension. Essential hypertension is defined by a blood pressure > 140 mmHg systolic and/or > 90mm diastolic confirmed before pregnancy or before 20 completed weeks gestation without a known cause. It may also be diagnosed in women presenting early in pregnancy taking antihypertensive medications where no secondary cause for hypertension has been determined. Important secondary causes of chronic hypertension in pregnancy include: • Chronic kidney disease, e.g. glomerulonephritis, reflux nephropathy, and adult polycystic kidney disease. • Renal artery stenosis • Systemic disease with renal involvement, e.g. diabetes mellitus, systemic lupus erythematosus. • Endocrine disorders, e.g. phaeochromocytoma, Cushing syndrome and primary hyperaldosteronism. • Coarctation of the aorta. In the absence of any of the above conditions it is likely that a woman with high blood pressure in the first half of pregnancy has essential hypertension. Collection methods: Diagnosis for eclampsia is to be based on the ICD-10-AM/ACHI/ACS (National Centre for Classification in Health, 2010). For all other value domains, diagnosis is to be based on Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) Guidelines for the Management of Hypertensive Disorders of Pregnancy. If the clinician does not have information as to whether the above guidelines have been used, available information about diagnosis of hypertensive disorder is still to be reported. The diagnosis is preferably derived from and substantiated by clinical documentation, which should be reviewed at the time of delivery. However this information may not be available in which case the patient may self-report to the clinician that they have been diagnosed with a hypertensive disorder. Source and reference attributes Reference documents: Lowe SA, Brown MA, Dekker G, Gatt S, McLintock C, McMahon L et al. 2008. Guidelines for the management of hypertension in pregnancy. Society of Obstetric Medicine of Australia and New Zealand The 10-AM Commandments (Coding Matters) in NCCH (National Centre for Classification in Health) 2010. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM), Australian Classification of Health Interventions (ACHI) and Australian Coding Standards (ACS), Seventh edition. Sydney: University of Sydney. Data set specification specific attributes Perinatal DSS 2015-16 Conditional obligation: This data element is conditional on Female—hypertensive disorder during pregnancy indicator, yes/no/not stated/inadequately described code N being coded to Yes. Data element attributes Relational attributes Related metadata references: See also Female—hypertensive disorder during pregnancy indicator, yes/no/not stated/inadequately described code N Health, Standard 07/03/2014 Implementation in Data Set Specifications: Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

integer

Description

Person—height (measured), total centimetres NN[N].N Identifying and definitional attributes Short name: Height (measured) METeOR identifier: 270361 Registration status: Health, Standard 01/03/2005 Definition: The height of a person measured in centimetres. Context: Public health and health care Data Element Concept: Person—height Value domain attributes Representational attributes Representation class: Total Data type: Number Format: NN[N].N Maximum character length: 4 Supplementary values: Value Meaning 999.9 Not measured Unit of measure: Centimetre (cm) Data set specification specific attributes Perinatal DSS 2015-16 Conditional obligation: It is preferable to collect and record a pregnant woman's height as a measured height. Where a measured height has not been provided or it is not possible to ascertain whether the height has been measured or self-reported, the value 999.9 should be recorded against this data item to indicate this. Data should then be recorded against the conditional self-reported height item. DSS specific information: It is acceptable for measured height to be rounded to the nearest centimetre. Data element attributes Collection and usage attributes Guide for use: In order to ensure consistency in measurement, the measurement protocol described under Collection methods should be used. Measurements of height should be assessed in relation to children and adolescents' age and pubertal status. Collection methods: The measurement protocol described below are those recommended by the International Society for the Advancement of Kinanthropometry as described by Norton et al. (1996), and the World Health Organization (WHO Expert Committee 1995), which was adapted from Lohman et al. (1988). Measurement protocol: Height measurements can be based on recumbent length or standing height. In general, length measurements are recommended for children under 2 years of age and height measurements for others. The measurement of height requires a vertical metric rule, a horizontal headboard, and a non-compressible flat even surface on which the subject stands. The equipment may be fixed or portable, and should be described and reported. The graduations on the metric rule should be at 0.1 cm intervals, and the metric rule should have the capacity to measure up to at least 210 cm. Measurement intervals and labels should be clearly readable under all conditions of use of the instrument. Apparatus that allows height to be measured while the subject stands on a platform scale is not recommended. Adults and children who can stand: The subject should be measured without shoes (i.e. is barefoot or wears thin socks) and wears little clothing so that the positioning of the body can be seen. Anything that may affect or interfere with the measurement should be noted on the data collection form (e.g. hairstyles and accessories, or physical problems). The subject stands with weight distributed evenly on both feet, heels together, and the head positioned so that the line of vision is at right angles to the body. The correct position for the head is in the Frankfort horizontal plan (Norton et al. 1996). The arms hang freely by the sides. The head, back, buttocks and heels are positioned vertically so that the buttocks and the heels are in contact with the vertical board. To obtain a consistent measure, the subject is asked to inhale deeply and stretch to their fullest height. The measurer applies gentle upward pressure through the mastoid processes to maintain a fully erect position when the measurement is taken. Ensure that the head remains positioned so that the line of vision is at right angles to the body, and the heels remain in contact with the base board. The movable headboard is brought onto the top of the head with sufficient pressure to compress the hair. The measurement is recorded to the nearest 0.1 cm. Take a repeat measurement. If the two measurements disagree by more than 0.5 cm, then take a third measurement. All raw measurements should be recorded on the data collection form. If practical, it is preferable to enter the raw data into the database as this enables intra-observer and, where relevant, inter-observer errors to be assessed. The subject's measured height is subsequently calculated as the mean of the two observations, or the mean of the two closest measurements if a third is taken, and recorded on the form. If only a mean value is entered into the database then the data collection forms should be retained. It may be necessary to round the mean value to the nearest 0.1 cm. If so, rounding should be to the nearest even digit to reduce systematic over reporting (Armitage & Berry 1994). For example, a mean value of 172.25 cm would be rounded to 172.2 cm, while a mean value of 172.35 cm would be rounded to 172.4 cm. Infants: For the measurement of supine length of children up to and including 2 years of age, two observers are required. One observer positions the head correctly while the other ensures the remaining position is correct and brings the measuring board in contact with the feet. The subject lies in a supine position on a recumbent length table or measuring board. The crown of the head must touch the stationary, vertical headboard. The subject's head is held with the line of vision aligned perpendicular to the plane of the measuring surface. The shoulders and buttocks must be flat against the table top, with the shoulders and hips aligned at right angles to the long axis of the body. The legs must be extended at the hips and knees and lie flat against the table top and the arms rest against the sides of the trunk. The measurer must ensure that the legs remain flat on the table and must shift the movable board against the heels. In infants care has to be taken to extend the legs gently. In some older children two observers may also be required. In general, length or height is measured and reported to the nearest 0.1 cm. For any child, the length measurement is approximately 0.5 - 1.5 cm greater than the height measurement. It is therefore recommended that when a length measurement is applied to a height-based reference for children over 24 months of age (or over 85 cm if age is not known), 1.0 cm be subtracted before the length measurement is compared with the reference. It is also recommended that as a matter of procedure and data recording accuracy, the date be recorded when the change is made from supine to standing height measure. Validation and quality control measures: All equipment, whether fixed or portable should be checked prior to each measurement session to ensure that both the headboard and floor (or footboard) are at 90 degrees to the vertical rule. With some types of portable anthropometer it is necessary to check the correct alignment of the headboard, during each measurement, by means of a spirit level. Within- and, if relevant, between-observer variability should be reported. They can be assessed by the same (within-) or different (between-) observers repeating the measurement of height, on the same subjects, under standard conditions after a short time interval. The standard deviation of replicate measurements (technical error of measurement (Pederson & Gore 1996)) between observers should not exceed 5 mm and be less than 5 mm within observers. Extreme values at the lower and upper end of the distribution of measured height should be checked both during data collection and after data entry. Individuals should not be excluded on the basis of true biological difference. Last digit preference, and preference or avoidance of certain values, should be analysed in the total sample and (if relevant) by observer, survey site and over time if the survey period is long. Comments: This metadata item applies to persons of all ages. It is recommended for use in population surveys and health care settings. It is recommended that in population surveys, sociodemographic data including ethnicity should be collected, as well as other risk factors including physiological status (e.g. pregnancy), physical activity, smoking and alcohol consumption. Summary statistics may need to be adjusted for these variables. Metadata items currently exist for sex, date of birth, country of birth, Indigenous status and smoking. Metadata items are being developed for physical activity. Presentation of data: Means, 95% confidence intervals, medians and centiles should be reported to one decimal place. Where the sample permits, population estimates should be presented by sex and 5-year age groups. However 5-year age groups are not generally suitable for children and adolescents. Estimates based on sample surveys may need to take into account sampling weights. For consistency with conventional practice, and for current comparability with international data sets, recommended centiles are 5, 10, 15, 25, 50, 75, 85, 90 and 95. To estimate the 5th and 95th centiles, a sample size of at least 200 is recommended for each group for which the centiles are being specified. For some reporting purposes, it may be desirable to present height data in categories. It is recommended that 5 cm groupings are used for this purpose. Height data should not be rounded before categorisation. The following categories may be appropriate for describing the heights of Australian men, women, children and adolescents although the range will depend on the population: Height 70 cm = Height 75 cm = Height ... in 5 cm categories 185 cm = Height Height => 190 cm Relational attributes Related metadata references: Is used in the formation of Adult—body mass index (measured), ratio NN[N].N[N] Health, Standard 01/03/2005 Is used in the formation of Adult—body mass index (self-reported), ratio NN[N].N[N] Health, Standard 01/03/2005, National Health Performance Authority, Standard 24/10/2013 Is used in the formation of Child—body mass index (measured), ratio NN[N].N[N] Health, Standard 01/03/2005 Is used in the formation of Child—body mass index (self-reported), ratio NN[N].N[N] Health, Standard 01/03/2005 Supersedes Height - measured, version 2, DE, NHDD, NHIMG, Superseded 01/03/2005.pdf (28.7 KB) Implementation in Data Set Specifications: Acute coronary syndrome (clinical) DSS 2013- Health, Standard 02/05/2013 Cardiovascular disease (clinical) DSS Health, Standard 01/09/2012 Diabetes (clinical) DSS Health, Standard 21/09/2005 Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

float

Measurement units

• cm

Description

Person—height (self-reported), total centimetres NN[N] Obligation: Conditional Identifying and definitional attributes Short name: Height (self-reported) METeOR identifier: 270365 Registration status: Health, Standard 01/03/2005 Definition: A person's self-reported height, measured in centimetres. Data Element Concept: Person—height Value domain attributes Representational attributes Representation class: Total Data type: Number Format: NN[N] Maximum character length: 3 Supplementary values: Value Meaning 888 Unknown 999 Not stated/inadequately described Unit of measure: Centimetre (cm) Data set specification specific attributes Perinatal DSS 2015-16 Conditional obligation: It is preferable to collect and record a pregnant woman's height as a measured height. Where a measured height has not been provided or it is not possible to ascertain whether the height has been measured or self-reported, the value 999.9 should be recorded against the measured height data item to indicate this. Data should then be recorded against this conditional self-reported height item. DSS specific information: It is acceptable for a self-reported height to be rounded to the nearest whole centimetre. Data element attributes Collection and usage attributes Collection methods: The method of data collection, e.g. face to face interview, telephone interview or self-completion questionnaire, can affect survey estimates and should be reported. The data collection form should include a question asking the respondent what their height is. For example, the Australian Bureau of Statistics National Health Survey 1995 included the question 'How tall are you without shoes?'. The data collection form should allow for both metric (to the nearest 1 cm) and imperial (to the nearest 0.5 inch) units to be recorded. If practical, it is preferable to enter the raw data into the database before conversion of measures in imperial units to metric. However if this is not possible, height reported in imperial units can be converted to metric prior to data entry using a conversion factor of 2.54 cm to the inch. Rounding to the nearest 1 cm will be required for measures converted to metric prior to data entry, and may be required for data reported in metric units to a greater level of precision than the nearest 1 cm. The following rounding conventions are desirable to reduce systematic over-reporting (Armitage & Berry 1994): NNN.x where x NNN.x where x > 5 - round up, e.g. 172.7 cm would be rounded to 173 cm. NNN.x where x = 5 - round to the nearest even number, e.g. 172.5 cm would be rounded to 172 cm, while 173.5 cm would be rounded to 174 cm. Comments: This metadata item is recommended for persons aged 18 years or older. It is recommended for use in population surveys when it is not possible to measure height. It is recommended that in population surveys, sociodemographic data including ethnicity should be collected, as well as other risk factors including physiological status (e.g. pregnancy), physical activity, smoking and alcohol consumption. Summary statistics may need to be adjusted for these variables. Metadata items currently exist for sex, date of birth, country of birth, Indigenous status and smoking. Metadata items are being developed for physical activity. Presentation of data: Means, 95% confidence intervals, medians and centiles should be reported to one decimal place. Where the sample permits, population estimates should be presented by sex and 5-year age groups. Estimates based on sample surveys may need to take into account sampling weights. For consistency with conventional practice, and for current comparability with international data sets, recommended centiles are 5, 10, 15, 25, 50, 75, 85, 90 and 95. To estimate the 5th and 95th centiles, a sample size of at least 200 is recommended for each group for which the centiles are being specified. For some reporting purposes, it may be desirable to present height data in categories. It is recommended that 5 cm groupings are used for this purpose. Height data should not be rounded before categorisation. The following categories may be appropriate for describing the heights of Australian men and women, although the range will depend on the population. The World Health Organization's range for height is 140-190 cm. Height <140 cm 140 cm = Height < 145 cm 145 cm = Height < 150 cm ... in 5 cm categories 185 cm = Height < 190 cm Height => 190 cm On average, height tends to be overestimated when self-reported by respondents. Data for Australian men and women aged 20-69 years in 1989 indicated that men overestimated by an average of 1.1 cm (SEM* of 0.04 cm) and women by an average of 0.5 cm (SEM of 0.05 cm) (Waters 1993). The extent of overestimation varied with age. *Note: SEM is the standard error of measurement. Relational attributes Related metadata references: Is used in the formation of Adult—body mass index (self-reported), ratio NN[N].N[N] Health, Standard 01/03/2005, National Health Performance Authority, Standard 24/10/2013 Is used in the formation of Child—body mass index (self-reported), ratio NN[N].N[N] Health, Standard 01/03/2005 Supersedes Height - self-reported, version 2, DE, NHDD, NHIMG, Superseded 01/03/2005.pdf (21.0 KB) Implementation in Data Set Specifications: Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

float

Measurement units

• cm

Description

Person—weight (measured), total kilograms N[NN].N Identifying and definitional attributes Short name: Weight in kilograms (measured) Synonymous names: Infant weight, neonate, stillborn METeOR identifier: 270208 Registration status: Health, Standard 01/03/2005 Definition: The weight (body mass) of a person measured in kilograms. Data Element Concept: Person—weight Value domain attributes Representational attributes Representation class: Total Data type: Number Format: N[NN].N Maximum character length: 4 Supplementary values: Value Meaning 999.9 Not collected Unit of measure: Kilogram (Kg) Unit of measure precision: 1 Collection and usage attributes Guide for use: A continuous variable measured to the nearest 0.1 kg. CODE 999.9 Not collected Use this code if measured weight is not collected. Data set specification specific attributes Perinatal DSS 2015-16 Conditional obligation: It is preferable to collect and record a pregnant woman's weight as a measured weight. Where a measured weight has not been provided or it is not possible to ascertain whether the weight has been measured or self-reported, the value 999.9 should be recorded against this data item to indicate this. Data should then be recorded against the conditional self-reported weight item. DSS specific information: Weight rounded to the nearest whole kilogram is acceptable. Weight should be recorded in the first trimester, preferably as a measured weight. However, the woman's self-reported weight around the time of conception is acceptable if a measured weight is not available. Data element attributes Collection and usage attributes Guide for use: In order to ensure consistency in measurement, the measurement protocol described under Collection methods should be used. Collection methods: The collection of anthropometric measurements, particularly in those who are overweight or obese or who are concerned about their weight, should be performed with great sensitivity and without drawing attention to an individual's weight. The measurement protocol described below is that recommended by the WHO Expert Committee (1995). Measurement protocol: Equipment used should be described and reported. Scales should have a resolution of at least 0.1kg and should have the capacity to weigh up to at least 200 kg. Measurement intervals and labels should be clearly readable under all conditions of use of the instrument. Scales should be capable of being calibrated across the entire range of measurements. Precision error should be no more than 0.1kg. Scales should be calibrated on each day of use. Manufacturers' guidelines should be followed with regard to the transportation of the scales. Adults and children who can stand: The subject stands over the centre of the weighing instrument, with the body weight evenly distributed between both feet. Heavy jewellery should be removed and pockets emptied. Light indoor clothing can be worn, excluding shoes, belts, and sweater. Any variations from light indoor clothing (e.g. heavy clothing, such as kaftans or coats worn because of cultural practices) should be noted on the data collection form. Adjustments for non-standard clothing (i.e. other than light indoor clothing) should only be made in the data checking/cleaning stage prior to data analysis. If the subject has had one or more limbs amputated, record this on the data collection form and weigh them as they are. If they are wearing an artificial limb, record this on the data collection form but do not ask them to remove it. Similarly, if they are not wearing the limb, record this but do not ask them to put it on. The measurement is recorded to the nearest 0.1 kg. If the scales do not have a digital readout, take a repeat measurement. If the two measurements disagree by more than 0.5 kg, then take a third measurement. All raw measurements should be recorded on the data collection form. If practical, it is preferable to enter the raw data into the database as this enables intra-observer and, where relevant, inter-observer errors to be assessed. The subject's measured weight is subsequently calculated as the mean of the two observations, or the mean of the two closest measurements if a third is taken, and recorded on the form. If only a mean value is entered into the database then the data collection forms should be retained. It may be necessary to round the mean value to the nearest 0.1 kg. If so, rounding should be to the nearest even digit to reduce systematic over reporting (Armitage and Berry 1994). For example, a mean value of 72.25 kg would be rounded to 72.2 kg, while a mean value of 72.35 kg would be rounded to 72.4 kg. Infants: Birth weight and gender should be recorded with gestational age. During infancy a levelled pan scale with a bean and movable weights or digital scales capable of measuring to two decimal places of a kilogram are acceptable. Birth weight should be determined within 12 hours of birth. The infant, with or without a nappy or diaper is placed on the scales so that the weight is distributed equally about the centre of the pan. When the infant is lying or suspended quietly, weight is recorded to the nearest 10 grams. If the nappy or diaper is worn, its weight is subtracted from the observed weight i.e. reference data for infants are based on nude weights. Validation and quality control measures: If practical, equipment should be checked daily using one or more objects of known weight in the range to be measured. It is recommended that the scale be calibrated at the extremes and in the mid range of the expected weight of the population being studied. Within- and, if relevant, between-observer variability should be reported. They can be assessed by the same (within -) or different (between-) observers repeating the measurement of weight, on the same subjects, under standard conditions after a short time interval. The standard deviation of replicate measurements (technical error of measurement) between observers should not exceed 0.5 kg and be less than 0.5 kg within observers. Extreme values at the lower and upper end of the distribution of measured height should be checked both during data collection and after data entry. Individuals should not be excluded on the basis of true biological difference. Last digit preference, and preference or avoidance of certain values, should be analysed in the total sample and (if relevant) by observer, survey site and over time if the survey period is long. Comments: This metadata item applies to persons of all ages. It is recommended for use in population surveys and health care settings. It is recommended that in population surveys, sociodemographic data including ethnicity should be collected, as well as other risk factors including physiological status (e.g. pregnancy), physical activity, smoking and alcohol consumption. Summary statistics may need to be adjusted for these variables. Metadata items currently exist for sex, date of birth, country of birth, Indigenous status and smoking. Metadata items are being developed for physical activity. Presentation of data: Means and 95% confidence intervals, medians and centiles should be reported to one decimal place. Where the sample permits, population estimates should be presented by sex and 5-year age groups. However 5-year age groups are not generally suitable for children and adolescents. Estimates based on sample surveys may need to take into account sampling weights. For consistency with conventional practice, and for current comparability with international data sets, recommended centiles are 5, 10, 15, 25, 50, 75, 85, 90 and 95. To estimate the 5th and 95th centiles, a sample size of at least 200 is recommended for each group for which the centiles are being specified. For some reporting purposes, it may be desirable to present weight data in categories. It is recommended that 5 kg groupings are used for this purpose. Weight data should not be rounded before categorisation. The following categories may be appropriate for describing the weights of Australian men, women, children and adolescents, although the range will depend on the population. Weight 10 kg = Weight 15 kg = Weight ... in 5 kg categories 135 kg = Weight Weight => 140 kg Source and reference attributes Submitting organisation: World Health Organization The consortium to develop standard methods for the collection and collation of anthropometric data in children as part of the National Food and Nutrition Monitoring and Surveillance Project, funded by the Commonwealth Department of Health and Ageing Reference documents: Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults (US National Heart, Lung and Blood Institute (NHLBI) in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases). Chronic Diseases and Associated Risk Factors in Australia 2001 (AIHW). Relational attributes Related metadata references: Is used in the formation of Adult—body mass index (measured), ratio NN[N].N[N] Health, Standard 01/03/2005 Is used in the formation of Adult—body mass index (self-reported), ratio NN[N].N[N] Health, Standard 01/03/2005, National Health Performance Authority, Standard 24/10/2013 Is used in the formation of Child—body mass index (measured), ratio NN[N].N[N] Health, Standard 01/03/2005 Is used in the formation of Child—body mass index (self-reported), ratio NN[N].N[N] Health, Standard 01/03/2005 Supersedes Weight - measured, version 2, DE, NHDD, NHIMG, Superseded 01/03/2005.pdf (29.3 KB) Implementation in Data Set Specifications: Acute coronary syndrome (clinical) DSS 2013- Health, Standard 02/05/2013 Cardiovascular disease (clinical) DSS Health, Standard 01/09/2012 Diabetes (clinical) DSS Health, Standard 21/09/2005 Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

float

Measurement units

• Kg

Description

Person—weight (self-reported), total kilograms NN[N] Obligation: Conditional Identifying and definitional attributes Short name: Weight (self-reported) METeOR identifier: 302365 Registration status: Health, Standard 14/07/2005 Definition: A person's self-reported weight (body mass). Data Element Concept: Person—weight Value domain attributes Representational attributes Representation class: Total Data type: Number Format: NN[N] Maximum character length: 3 Supplementary values: Value Meaning 888 Unknown 999 Not stated Unit of measure: Kilogram (Kg) Collection and usage attributes Guide for use: CODE 888 Unknown Use this code if self-reported body mass (weight) is unknown. CODE 999 Not stated Use this code if self-reported body mass (weight) is not responded to. Data set specification specific attributes Perinatal DSS 2015-16 Conditional obligation: It is preferable to collect and record a pregnant woman's weight as a measured weight. Where a measured weight has not been provided or it is not possible to ascertain whether the weight has been measured or self-reported, the value 999.9 should be recorded against the measured weight data item to indicate this. Data should then be recorded against this conditional self-reported weight item. DSS specific information: Weight rounded to the nearest whole kilogram is acceptable. Weight should be recorded in the first trimester, preferably as a measured weight. However, the woman's self-reported weight around the time of conception is acceptable if a measured weight is not available. Data element attributes Collection and usage attributes Collection methods: The method of data collection, e.g. face to face interview, telephone interview or self-completion questionnaire, can affect survey estimates and should be reported. The data collection form should include a question asking the respondent what their weight is. For example, the ABS National Health Survey 1989-90 included the question 'How much do you weigh without clothes and shoes?'. The data collection form should allow for both metric (to the nearest 1 kg) and imperial (to the nearest 1 lb) units to be recorded. If practical, it is preferable to enter the raw data into the data base before conversion of measures in imperial units to metric. However, if this is not possible, weight reported in imperial units can be converted to metric prior to data entry using a conversion factor of 0.454 kg to the lb. Rounding to the nearest 1 kg will be required for measures converted to metric prior to data entry, and may be required for data reported in metric units to a greater level of precision than the nearest 1 kg. The following rounding conventions are desirable to reduce systematic over reporting (Armitage and Berry 1994): nnn.x where x nnn.x where x > 5 - round up, e.g. 72.7 kg would be rounded to 73 kg. nnn.x where x = 5 - round to the nearest even number, e.g. 72.5 kg would be rounded to 72 kg, while 73.5 kg would be rounded to 74 kg. Comments: This metadata item is recommended for persons aged 18 years or older. It is recommended for use in population surveys when it is not possible to measure weight. It is recommended that in population surveys, sociodemographic data including ethnicity should be collected, as well as other risk factors including physiological status (e.g. pregnancy), physical activity, smoking and alcohol consumption. Summary statistics may need to be adjusted for these variables. Metadata items currently exist for sex, date of birth, country of birth, Indigenous status and smoking. Metadata items are being developed for physical activity. Presentation of data: Means and 95% confidence intervals, medians and centiles should be reported to one decimal place. Where the sample permits, population estimates should be presented by sex and 5-year age groups. Estimates based on sample surveys may need to take into account sampling weights. For consistency with conventional practice, and for current comparability with international data sets, recommended centiles are 5, 10, 15, 25, 50, 75, 85, 90 and 95. To estimate the 5th and 95th centiles, a sample size of at least 200 is recommended for each group for which the centiles are being specified. For some reporting purposes, it may be desirable to present weight data in categories. It is recommended that 5 kg groupings are used for this purpose. Weight data should not be rounded before categorisation. The following categories may be appropriate for describing the weights of Australian men and women, although the range will depend on the population. The World Health Organization's range for weight is 30-140 kg. Weight 30 kg = Weight 35 kg = Weight ... in 5 kg categories 135 kg = Weight Weight => 140 kg On average, body mass (weight) tends to be underestimated when self-reported by respondents. Data for men and women aged 20-69 years in 1989 indicated that men underestimated by an average of 0.2 kg (sem of 0.05 kg) and women by an average of 0.4 kg (sem of 0.04 kg) (Waters 1993). The extent of underestimation varied with age. Source and reference attributes Origin: National Centre for Monitoring Cardiovascular Disease Australian Institute of Health and Welfare National Health Data Committee Relational attributes Related metadata references: Is used in the formation of Adult—body mass index (self-reported), ratio NN[N].N[N] Health, Standard 01/03/2005, National Health Performance Authority, Standard 24/10/2013 Supersedes Adult—weight (self-reported), total kilograms NN[N] Health, Superseded 14/07/2005 Is used in the formation of Child—body mass index (self-reported), ratio NN[N].N[N] Health, Standard 01/03/2005 Supersedes Weight - self-reported, version 2, DE, NHDD, NHIMG, Superseded 01/03/2005.pdf (20.5 KB) Implementation in Data Set Specifications: Perinatal DSS 2015-16 Health, Standard 13/11/2014

Data type

float

Measurement units

• Kg