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Vaginal Delivery
S. Katherine Laughon, MD, MS, Jun Zhang, PhD, MD, James Troendle, PhD, Liping Sun, MD, MS,
and Uma M. Reddy, MD, MPH
OBJECTIVE: The Bishop score is the most commonly vaginal delivery (P<.01). The simplified Bishop score
used method to assess the readiness of the cervix for was then devised using these three components (range
induction. However, it was created without modern 0 –9) and compared with the original Bishop score
statistical methods. Our objective was to determine (range 0 –13) for prediction of successful induction,
whether a simplified score can predict vaginal delivery resulting in vaginal delivery. Compared with the original
equally well. Bishop score (greater than 8), the simplified Bishop score
METHODS: Data were analyzed for 5,610 nulliparous (greater than 5) had a similar or better positive predictive
women with singleton, uncomplicated pregnancies be- value (87.7% compared with 87.0%), negative predictive
tween 37 0/7 and 41 6/7 weeks of gestation undergoing value (31.3% compared with 29.8%), positive likelihood
labor induction. These women had all five components of ratio (2.34 compared with 2.19), and correct classification
the Bishop score recorded. Logistic regression was per- rate (51.0% compared with 47.3%). Application of the
formed and a simplified score created with significant simplified Bishop score in other populations, including
components. Positive and negative predictive values and indicated induction and spontaneous labor at term and
positive likelihood ratios were calculated. preterm, were associated with similar vaginal delivery
rates compared with the original Bishop score.
RESULTS: In the regression model, only dilation, sta-
CONCLUSION: The simplified Bishop score comprised
tion, and effacement were significantly associated with
of dilation, station, and effacement attains a similarly high
predictive ability of successful induction as the original
From the Eunice Kennedy Shriver National Institute of Child Health and score.
Human Development, National Institutes of Health, Bethesda, Maryland. (Obstet Gynecol 2011;117:805–11)
The data included in this article were obtained from the Consortium on Safe DOI: 10.1097/AOG.0b013e3182114ad2
Labor, which was supported by the Intramural Research Program of the Eunice
Kennedy Shriver National Institute of Child Health and Human Develop- LEVEL OF EVIDENCE: II
ment, National Institutes of Health, through Contract No.
HHSN267200603425C. Institutions involved in the Consortium include, in
alphabetical order: Baystate Medical Center, Springfield, Massachusetts; Ce-
dars-Sinai Medical Center Burnes Allen Research Center, Los Angeles, Califor-
nia; Christiana Care Health System, Newark, Delaware; Georgetown Univer-
sity Hospital, MedStar Health, Washington, DC; Indiana University Clarian
I n the 1960s, Dr Edward Bishop developed a pelvic
scoring system using cervical dilatation, effacement,
station, consistency, and position with a possible
Health, Indianapolis, Indiana; Intermountain Healthcare and the University of range from 0 to 13.1 Based on clinical experience, he
Utah, Salt Lake City, Utah; Maimonides Medical Center, Brooklyn, New York;
MetroHealth Medical Center, Cleveland, Ohio; Summa Health System, Akron
concluded that elective induction in multiparous
City Hospital, Akron, Ohio; The EMMES Corporation, Rockville, Maryland women with uncomplicated pregnancies at term was
(Data Coordinating Center); University of Illinois at Chicago, Chicago, Illinois; successful with a score of greater than 8.
University of Miami, Miami, Florida; and University of Texas Health Science
Center at Houston, Houston, Texas. Shortly after the Bishop score was introduced,
Presented as a poster at the Annual Meeting of the Society for Maternal-Fetal
other investigators created weighting for the compo-
Medicine, February 10, 2011, San Francisco, CA. nents of the score and found that cervical dilation was
Corresponding author: S. Katherine Laughon, MD, MS, Epidemiology Branch, more associated with the time of the latent phase
NICHD, National Institutes of Health,. 6100 Executive Boulevard, Room compared with the other components. However, the
7B03, Rockville, MD 20852; e-mail: laughonsk@mail.nih.gov.
weighted Bishop score did not provide a clinically
Financial Disclosure
The authors did not report any potential conflicts of interest.
significant improvement in predicting duration of
labor compared with the original score.2,3 New scores
© 2011 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins. have been proposed, the Bishop score has been
ISSN: 0029-7844/11 modified, and attempts have been made to improve
VOL. 117, NO. 4, APRIL 2011 Laughon et al Simplifying the Bishop Score 807
Table 2. The Original Bishop Score With Logistic Regression Results for Outcome of Vaginal Delivery
Subscore
Component Regression Coefficient* P 0 1 2 3
method resulted in dilation and station always being negative predictive value (31.3% for the simplified
chosen in the model and effacement chosen for 70.5% compared with 29.8% for the original score). The
of the different bootstrap samples, overall supporting positive likelihood ratio test and the correct classi-
our choice of cervical components from the regres- fication rate were also similar or slightly better
sion model (Table 3). (2.34% compared with 2.19% and 51.0% compared
At a given sensitivity and specificity for vaginal with 47.3%, respectively).
delivery, the positive predictive value, negative pre- We then compared the simplified Bishop score
dictive value, and correct classifications rates were with the original Bishop score for the following sepa-
similar to the original Bishop score compared with rate populations of women: term (37 0/7– 41 6/7
using a simplified Bishop score based on dilation, weeks of gestation) indicated induction and spontane-
effacement, and station only (Table 4). For example, ous labor and preterm (32 0/7–36 6/7 weeks of
using the original Bishop score greater than 8, the gestation) indicated induction and spontaneous labor.
simplified Bishop score with the closest sensitivity The simplified Bishop score was associated with a
and specificity would be greater than 5. Compared similar vaginal delivery rate compared with the orig-
with the original Bishop score greater than 8, the inal Bishop score (Fig. 1). For illustration, a simplified
simplified Bishop score greater than 5 had a similar Bishop score greater than 5 performed similarly to an
positive predictive value (87.7% for the simplified original Bishop score greater than 8 in both the
compared with 87.0% for the original score) and indicated inductions and spontaneous labor at term
and preterm with the similar correct classification
rates (Table 5).
Table 3. Bootstrap Method Results Evaluating
Regression Model With Outcome of
Vaginal Delivery*
DISCUSSION
In nulliparous women with uncomplicated pregnan-
Number of cies undergoing an induction of labor at term, a
Variables Percentage
Removed Variable(s) Removed of Samples simplified Bishop score with three components (dila-
tion, station, and effacement) predicted vaginal deliv-
0 None of the variables were 5.5 ery similarly to the original Bishop score. The simpli-
removed (full model contains six fied Bishop score also was comparable to the original
predictors: dilation, effacement,
station, consistency, position, Bishop score in predicting successful vaginal delivery
and site) in women with an indicated induction both at term
1 Consistency 17.3 and preterm between 32 and 36 6/7 weeks of gesta-
Position 10.7 tion. Even in women who presented in spontaneous
Effacement 6.0 labor at term and preterm, the simplified Bishop score
2 Consistency and position 37.0
Position and effacement 14.6 was similar to the original Bishop score, suggesting
Consistency and effacement 2.9 that the simplified score is equivalent to the original
3 Consistency, position, and 6.0 score in the setting that it was developed.
effacement Other attempts at modifying or evaluating the
* Bootstrap samples (n⫽1,000) of the same size as the original Bishop score have used different outcomes such as
data set were used. Logistic regression was performed with length of labor or achieving active labor, and many
P⬍.01 significance level of the Wald 2 for an effect to stay
in the model in a backward-elimination step using the included multiparous women who are known to have
resample. more successful inductions.3–5,7 We chose vaginal
Original Bishop
Greater than 5 75.1 49.2 81.8 39.3 1.47 68.7
Greater than 6 62.9 62.8 83.8 35.7 1.69 62.9
Greater than 7 49.8 75.8 86.2 33.1 2.05 56.2
Greater than 8 35.3 83.8 87.0 29.8 2.19 47.3
Simplified Bishop
Greater than 3 75.8 49.3 82.0 40.1 1.49 69.4
Greater than 4 59.2 67.9 84.9 35.3 1.84 61.4
Greater than 5 40.6 82.6 87.7 31.3 2.34 51.0
Greater than 6 18.8 94.2 90.8 27.6 3.25 37.4
PPV, positive predictive value; NPV, negative predictive value; LR, likelihood ratio (calculated as sensitivity/关1⫺specificity兴; the correct
classification rate was calculated as number of true positives⫹number of true negatives/number of patients classified).
Data are % unless otherwise specified.
* Original Bishop score includes dilation, effacement, station, consistency, and position, with a possible range from 0 to 13; simplified
Bishop score includes dilation, station, and effacement only, with a possible range from 0 to 9.
delivery as the primary outcome, because this is what There is a possibility that women who had all five
clinicians and patients define as success. Our study components of the Bishop score recorded are differ-
also has the advantage of having a large number of ent in baseline characteristics from women who were
nulliparous women. Thus, we were able to use mod- missing some of the components. However, most of
ern statistical methods to find which components of the women (72.2%) had dilation, station, and efface-
the Bishop score were independently associated with ment present, and many clinicians informally already
vaginal delivery to create a simplified score. use a simplified Bishop score. It is more likely that the
VOL. 117, NO. 4, APRIL 2011 Laughon et al Simplifying the Bishop Score 809
Table 5. Application of Simplified Bishop Score in Different Populations for Success of Vaginal Delivery*
Correct
Vaginal Positive Classification
Population n† Delivery Sensitivity Specificity PPV NPV LR Rate
recording of some compared with five components of dilation likely because we had a large number of
the Bishop score was based on clinician preference women and thus more power. Although the addition
rather than something inherently different about a of position or consistency may be significantly asso-
woman undergoing an induction. Given the large ciated with successful vaginal delivery in a different
numbers, we were able to test the simplified score in population of women, the purpose of our model was
other populations of women, including indicated to simplify the score, so we chose only the compo-
induction and spontaneous labor both term and nents that were both highly significant in the regres-
preterm, and the simplified Bishop score performed sion and contributed the most to vaginal delivery as
similarly to the original Bishop score in predicting determined by the regression coefficients. Of note,
vaginal delivery in all of these settings, which simplifying the score even further by using only the
suggests that missing cervical components were two components with the highest regression coeffi-
likely not an issue. cients, dilation and station, resulted in a worse correct
Our findings are similar to a prospective study of classification rate compared with the simplified
134 women undergoing an induction of labor at term, Bishop score using all three components of dilation,
in which only the cervical components of dilation and station, and effacement (data not shown). Our find-
effacement were associated with vaginal delivery ings are also supported by a secondary analysis of
within 24 hours.15 Using an “abbreviated” Bishop four randomized controlled trials with a total of 781
score including dilation and effacement only greater women comparing different induction methods for
than 3, the predictive characteristics of vaginal deliv- indicated induction after 37 weeks of gestation, and
ery (excluding 23 women who had an emergency the cervical components dilation, effacement, and
cesarean delivery for maternal or fetal indications) station were independently associated with vaginal
were positive predictive value 85.5%, negative predic- delivery within 24 hours after adjusting for maternal
tive value 65.7%, and positive likelihood ratio ⫹2.61, and obstetric characteristics, although only position
which were similar to our simplified Bishop score and station were associated with spontaneous vaginal
greater than 5. An older, smaller study of 40 nullipa- delivery.17
rous and 69 multiparous women also found that only Other studies have created variations of the
dilation was associated with the length of latent phase Bishop score. In a prospective study of 1,189 women
of labor after labor induction.16 Our study found both undergoing induction mostly for indicated indica-
effacement and station to be significant in addition to tions, Lange et al.7 used linear regression to create a
VOL. 117, NO. 4, APRIL 2011 Laughon et al Simplifying the Bishop Score 811