E78.5 - Hyperlipidemia, unspecified

Clinical Definition

Vaginal delivery is the process of giving birth through the vaginal canal, where the baby passes through the cervix and birth canal naturally. For coding purposes, this specifically describes a delivery managed primarily by the delivering provider without complications or assistance.

Documentation Requirements

• Date and time of delivery

• Gestational age at delivery

• Spontaneous vs. induced labor

• Confirmation that delivery was completed without instruments

• Absence of complications during delivery

• Documentation of placental delivery (3rd stage)

• Status of perineum (intact vs. tear/laceration)

• Estimated blood loss (EBL)

Common Synonyms

• Natural birth

• Normal delivery

• Spontaneous vaginal delivery (SVD)

• NSVD (Normal Spontaneous Vaginal Delivery)

• "Regular birth"

Coding Conflicts

Excludes1:

• Assisted vaginal delivery

• Delivery by forceps or vacuum extraction

• Breech delivery

• Multiple gestation delivery

Excludes2:

• Failed attempt at vaginal delivery

• Management of pregnancy with delivery by C-section

Scribing.io Automation

The AI scribe automatically detects and documents key phrases like:

• "Uncomplicated vaginal delivery"

• "Spontaneous vaginal birth"

• EBL amounts

• Time stamps of delivery stages

• Perineal status descriptors

It flags missing elements required for coding, such as undocumented placental delivery or gestational age.