Caput succedaneum

This code represents a localized, edematous swelling of the fetal scalp that occurs during labor, typically due to pressure from the dilating cervix or vaginal walls. It is a benign condition resulting from serosanguinous fluid accumulation above the periosteum and often crosses suture lines.

Use this code when documentation clearly indicates a diagnosis of caput succedaneum in a newborn. This condition is commonly observed after prolonged labor, vacuum extraction, or forceps delivery. Documentation should specify the presence of scalp swelling that is soft, pitting, and crosses suture lines.

• Differentiate from cephalohematoma, which is a subperiosteal hemorrhage that does not cross suture lines.
• This code is typically a secondary diagnosis, with the primary diagnosis often related to the newborn's birth or other perinatal conditions.
• Ensure the medical record specifies "caput succedaneum" and not just "scalp swelling" to support accurate coding.