Ausr N Z J Obstet Gynaecol

1987; 21: 309

Evaluation of Preinduction Scoring Systems

K. Dhall’, S. C. Mittal’ and Anita Kumar’

Lkpartment of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research,
Chandigurh, India

Summary: Two hundred patients requiring induction of labour were assigned

a preinduction score according to Dhall’s criteria and Bishop’s criteria. A score of
9 or more (Dhall) and 6 or more (Bishop) had favourable outcomes with successful
induction in more than 90% of patients and an induction delivery interval (IDI)
of less than 12 hours. In multiparas a Dhall score of more than 7 had a sensitivity
and specificity of 88.6% and 90.0% respectively in predicting induction outcome
compared to Bishop score sensitivity of 86.3% and low specificity of 47.4%.
Correlation of the score with ID1 as a dependent variable also showed that the
Dhall score had a better predictive value than the Bishop score.

An ideal scoring system that accurately predicts safe
and successful induction of labour whether indicated
or elective and applicable to both primiparas and
multiparas is lacking. Dhall et al (1986)(1) devised a
new scoring system based on the best subset derived
from 1 1 factors following complicated regression
analysis. This score is simple, gives accurate descrip-
tion of the cervix and is applicable equally to pri-
miparas and multiparas (table 1). The purpose of the
present study was to prospectively evaluate this scor-
ing system in prediction of induction outcome.
aware of the patient’s induction score. The technique
of induction depended on the clinical findings. Oxy-
twin infusion up to 16 mu/minute was used in the
majority of patients (in 87 alone and in 102 combined
with amniotomy). Amniotomy as a primary method
of induction was used only in 11 patients. Induction
was considered to be successful when it resulted in
vaginal delivery, spontaneous or aided by low forceps
within 24 hours. Statistical analysis of the data was
carried out by coefficient of determination and stu-
dent’s t-test.

Table 1. DhaM Scoring System

MATERIALS A N D METHODS
Effacement 0-30% ~ 6 0 % >60%
0 1 2
Two hundred patients with periods of gestation Consistency Firm Medium Soft
from 36 to 43 weeks were studied. The indication 0 2 4
for induction of labour was therapeutic in all cases, Dilatation Closed 1-2 em 3-4cm >4cm
the frequent ones being preeciampsia and other hy- 0 3 6 9
Parity Primipara Multipara
pertensive disorders (77), postdatism (5 I), premature 0 4
rupture of membranes (30) and intrauterine growth
retardation (11). On admission to the labour ward
each patient was evaluated by the attending obste- Tabk 2. Bishop Scoring Index
trician and factors necessary for induction scoring
Factors Numerical rati?g
were recorded. The study proforma was completed
after delivery and depending upon the initial pelvic 0 1 2 3
findings a score was assigned to each subject ac- Dilatation Closed 1-2 cm 3 4 cm 5 cm +
cording to DhalI score (table 1) and Bishop score (2), Effacement 0-30% 40-50% &70% 80% +
Station -3 -2 -1, 0 + I , +2
1%7 (table 2). Thus, the attending physician was not Consistency Firm Medium Soft -
Position Posterior Middle Anterior -
Score ranges from 0-13; prerequisites: multiparity, gestation
of at least 36 weeks, and vertex presentation with a normal
1. Professor. past and present obstetric history. Predictions: Patients with
2. Senior Resident. a score of 9 or more will have a safe, successful induction
3. Ex-Pool Officer. with an average length of labour of less than 4 hours.
310 AuSF. AND N.Z. JOURNALOF O m m AND GmAEcoLooY

T.Me 3. hectietioa of M u n Indection Delivery Intend (IDI)

and Success Rate
Score n Mean Success rate*
ID1 070 n
(hours)
Bishop 0-3 47 t9.4 46.8 22
score 4-5 82 15.9 68.3 56
56 71 9.4 91.6 65
Dhall 0-6 44 21.1 34.1 15
score 7-8 75 15.8 72.0 54
29 81 10.8 91.4 74
*Vaginal delivery with ID1 24 hours or iess

RESULTS

Of the 200 patients, 137 were primiparas and 63

multiparas. Induction was successful in 143 (71 5%);
of the remaining patients, 36 were delivered by Cae-
sarean section (18%) and 21 (10.5%) had an induc-
“1
30 SAMPLE
TOTAL
F’RIMIPARAS
n
elsHOP’s SWRE
WLTIPARAS

tion delivery interval (IDI) of more than 24 hours.

Figure 1 shows the distribution of score in all patients
according to Dhall and Bishop criteria; the mean
scores in all the patients and separately in primiparas
and multiparas were 9.1 and 5.1; 6.1 and 5.0; and
11.3 and 5.3 by the 2 scoring systems respectively.
Induction delivery interval and success rate of in-
duction was calculated in all patients in relation to
the score assigned by both scoring systems (table 3).
It is apparent that the higher the score, the higher
was the success rate and the less the IDI. It was also
found that a score of 6 or more (Bishop) (2) and 9
or more (Dhall) (1) had favourable outcomes. The
success rate is shown diagrammaticaiiy in figure 2
which shows that the prediction was almost 100% at
the extremes of the score with almost straight line
correlation as the score increased, while with the
Bishop score, the correlation was not good. The
maximum Bishop score noted in these patients was
Figure 1. Distribution of scores in primiparas (n = 137).
multiparas (n = 63); total sample (n = 200).
8 and none fulfilled Bishop’s prerequisite of favour-
ability. In multiparas a Dhall score of 7 or more
gave fairly accurate prediction with sensitivity of
88.6% and specificity of WVo. With a similar cut-
off point at 4 applied to a Bishop score the sensitivity
was 86.3% but the specificity (47.4%) was low. This
difference was statistically significant (p ~ 0 . 0 5 ) .
However, the difference was not statistically signifi-
cant when the 2 scoring systems were applied to
primiparas (table 4).

Vaginal delivery
ID1 CaaWan SUcceJs
Score n <24 hrs >24 hrs section (a)
Bishop
34 109 83 8 18 16.2
<4 28 12 8 8 42.8
Primiparas Dhd
>7 97 18 7 12 80.4
<7 40 17 9 14 42.5
(p > 0.05)
Bishoo
34 44 38 2 4 86.3
<4 19 10 1 8 52.6
Multiparas Dhall
27 53 41 3 3 88.6
<7 10 I 0 9 10.0
 K. DHALL,S.C. MITTALAND ANITAKUMAR
Figure 2. Success rate in relation to score by the 2 scoring
systems.
DISCUSSION
An ideal scoring system for induction of labour is
needed. This study shows that the Dhall scoring sys-
tem has improved upon the commonly used Bishop
scoring system in predicting inducibility. It is appli-
311
cable to all women whether primiparas or multiparas;
the prediction was nearly 100% at extremes of the
score, with a steadily decreasing failure rate as the
score increased (figure 2). In multiparas, a score of
7 or more had high sensitivity and specificity in
predicting inducibility. The prerequisites of the Bishop
widely used scoring system limited its applicability
as none of the patients in the present study met
Bishop's criteria of favourability. In deciding upon
induction, the clinical setting in a particular patient
is of paramount importance and should be weighed
against the probability of success and complications.
As factors responsible for initiation of labour are
still not clear, the mere physical characteristics of the
cervix cannot be expected to give 100% predictive
results in all women. The inducibility score should
be considered as a guide to risk assessment rather
than to decide whether or not induction should be
performed.
References
1. Dhall K, Grover V, Mahendru SK. Prelabour status eval-
uation and course of labour. Asia-Oceania J Obstet Gy-
naecol 1986; 1 2 25-31.
2. Bishop EH. Pelvic scoring for elective induction. Obstet
Gynecol 1%4,24: 266-268.