Caput succedaneum
ICD-10 P12.81 is a billable code used to indicate a diagnosis of caput succedaneum.
Caput succedaneum is a common condition observed in newborns, characterized by the accumulation of serous fluid in the soft tissues of the scalp, resulting from pressure during delivery. This condition typically occurs when the fetal head is compressed against the cervix during labor, leading to localized edema. Unlike cephalohematoma, which involves bleeding between the skull and periosteum, caput succedaneum is not confined by sutures and can cross suture lines. It is usually self-limiting, resolving within a few days without intervention. Clinically, it presents as a soft, boggy swelling on the head, often more pronounced at the vertex. While caput succedaneum is generally benign, it can be confused with other conditions such as cephalohematoma or chignon, which may require further evaluation. Accurate diagnosis and documentation are essential for appropriate coding and management of the newborn's care.
Detailed documentation of the delivery process, including duration of labor and any complications.
Newborns presenting with scalp swelling after a prolonged labor or vacuum-assisted delivery.
Ensure differentiation from cephalohematoma and document any associated findings.
Comprehensive history and physical examination findings, including any follow-up assessments.
Pediatric evaluations of newborns with head swelling during routine check-ups.
Consider the impact of delivery method on the incidence of caput succedaneum.
Used when a newborn with caput succedaneum is evaluated in the nursery.
Document the clinical findings and any parental education provided.
Neonatologists should ensure accurate coding based on the clinical assessment.
Caput succedaneum typically resolves within a few days without any medical intervention, although monitoring is essential to ensure no complications arise.
