The “Proportion of deliveries by primary cesarean section” is an indicator that can be used to assess the quality of care provided to mothers giving birth.
Hospitals and health systems are often compared based on this indicator, since lower values may reflect more appropriate clinical practice and that some cesarean sections may be performed for “non-medical reasons.”Data show a slight reduction in the proportion of deliveries by primary cesarean section in Italy from 2015 (25%) to 2021 (22%). The Ministry of Health Decree No. 70 of April 2, 2015, on hospital care standards establishes a maximum threshold for the proportion of primary cesarean sections that varies based on the type of hospital, but which must not exceed 25%. Comparisons between hospitals could, however, be distorted if the possible different distribution of patient risk factors for cesarean section were not taken into account. C-sections are indicated in many clinical situations, such as placental or cord complications, fetal distress, HIV infection, and fetal-pelvic disproportion.Furthermore, sociodemographic differences or differences in the availability of services for high-risk pregnancies increase the likelihood of a cesarean section. The primary cesarean section indicator is calculated as the proportion of a woman’s first cesarean section births.Since women with a previous cesarean birth are less likely to give birth vaginally, the indicator “Proportion of vaginal births in women with a previous cesarean birth” was calculated separately.This indicator measures vaginal births performed in a hospital setting among women who have previously given birth by cesarean section.
Data show a vaginal birth rate after a previous cesarean section of approximately 10.5% between 2018 and 2021. Episiotomy, which involves surgically incising the vulvovaginal orifice, is performed to facilitate the expulsive phase of labor and is a frequently performed routine procedure, despite the lack of evidence of its effectiveness, either in the short or medium-long term.Randomized, controlled clinical studies have shown that minimizing the use of episiotomy reduces the incidence of trauma and complications in the perineal area. The procedure was not associated with the expected benefits, such as reduced fetal trauma at birth, easier wound healing compared to vaginal lacerations, protection of the pelvic floor, and reduced pain upon resumption of sexual intercourse.However, routine episiotomy has been shown to increase the risk of postpartum blood loss, wound infection and dehiscence, poor cosmetic outcomes, and severe perineal lacerations in subsequent deliveries.
The NICE guideline “Intapartum care” and the WHO guidelines “Intrapartum care for a positive childbirth experience” recommend against routine episiotomy and only resorting to it when necessary.Sample surveys on the birth process in Italy, coordinated by the Istituto Superiore di Sanità, estimated an episiotomy rate of 69% in 2002, which dropped to 45% in 2008-09 and 42% in 2010-11.The indicator is not yet available in the national CedAP, but we do have some estimated regional prevalence data for the Autonomous Province of Trento, the Tuscany Region, and Emilia-Romagna, which in 2019-2020 ranged between 6 and 8%.
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Indicators 
