American Journal of Obstetrics and Gynecology (2004) 191, 1644e8

www.ajog.org

Modified Bishop’s score and induction of labor in patients

with a previous cesarean delivery
Emmanuel Bujold, MD,a,b,* Sean C. Blackwell, MD,b Israel Hendler, MD,b
Susan Berman, MD,b Yoram Sorokin, MD,b Robert J. Gauthier, MDa

Department of Obstetrics and Gynecology, Hôpital Ste-Justine, Universite´ de Montre´al, Montreal, Quebec, Canada,a
and Department of Obstetrics and Gynecology, Hutzel Hospital, Wayne State University, Detroit, Michb

Received for publication January 6, 2004; revised March 17, 2004; accepted March 25, 2004

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KEY WORDS Objectives: The purpose of this study was to evaluate the association between preinduction mod-
Bishop’s score ified Bishop’s score and obstetric outcome, including successful vaginal birth after prior cesarean
Vaginal birth after prior (VBAC) and uterine rupture in patients with a previous cesarean undergoing induction of labor.
cesarean Study design: Medical records of all patients who had an induction of labor after a previous ce-
Labor induction sarean in our institution between 1988 and 2002 were reviewed. Patients were divided into 4
groups according to the modified Bishop’s score (0 to 2, 3 to 5, 6 to 8, and 9 to 12). The rates
of successful VBAC, symptomatic uterine rupture, and other obstetric outcomes were evaluated
in each group. Multivariate regression analyses were performed to adjust for confounding factors.
Results: Out of 685 women included in the study, 187 (27.3%) had a modified Bishop’s score !2,
276 (40.3%) of 3 to 5, 189 (27.6%) of 6 to 8, and 33 (4.8%) of 9 to 12. The rate of successful
VBAC significantly correlated with the modified Bishop’s score (57.5%, 64.5%, 82.5%, and
97.0%, respectively, P ! .001). However, the rate of uterine rupture was not statistically signif-
icant between the groups (2.1%, 1.8%, 0.5%, 0.0%, P = .48). After adjusting for confounding
variables, a modified Bishop’s score R6 remained associated with successful VBAC (odds ratio
[OR] 2.07, 95% CI 1.28-3.35, P ! .001).
Conclusion: The modified Bishop’s score before induction of labor is an independent factor asso-
ciated with successful VBAC.
Ó 2004 Elsevier Inc. All rights reserved.
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In patients with an unscarred uterus, cervical status most common method to evaluate cervical status is the
correlates with the success of induction of labor.1 The Bishop’s score.2 In 1982, Lange et al proposed a modi-
fied Bishop’s score including cervical dilatation, fetal
head station and effacement, and doubling the number
Presented at the 71th Annual Meeting of the Central Association of of points for cervical dilatation.3 This method of evalu-
Obstetrics and Gynecology, La Jolla, California, October 1-4, 2003. ation of cervical status has been shown to correlate bet-
* Reprint requests: Emmanuel Bujold, MD, Hutzel Hospital,
Department of Obstetrics and Gynecology, Wayne State University,
ter with delivery outcome than the original Bishop’s
4707 St Antoine Boulevard, Detroit, MI 48201. score.3 Regardless of the cervical status, induction of la-
E-mail: ebujold@med.wayne.edu bor in patients with a previous caesarean delivery has

0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.ajog.2004.03.075
Bujold et al
been associated with a higher rate of failed trial of labor
(TOL) and a higher rate of uterine rupture.1,4 However,
there is a paucity of information regarding the associa-
tion between cervical status before induction of labor
and obstetric outcomes in patients with a previous cesar-
ean delivery.5
Because patients with a failed TOL after a previous
cesarean delivery have a higher rate of major maternal
complications (eg, uterine rupture, septicemia, and hys-
terectomy),6 efforts should be made to predict which pa-
tients are at the greatest risk of failed TOL. The purpose
of this study was to evaluate the effect of preinduction
cervical status on obstetric outcome in a population of
patients with a previous cesarean delivery.
Material and methods
This was a retrospective study including all women with
a previous low transverse cesarean delivery who under-
went an induction of labor in our institution at 24
weeks’ gestation or greater between January 1988 and
December 2002. Exclusion criteria were multiple gesta-
tion, intrauterine fetal death, and fetal anomalies. Three
databases were used to ensure that all cases were identi-
fied. The first database was the Perinatal Database of
Ste-Justine Hospital, where data collection began in
1988; the second was from the Medical Records Depart-
ment; and the third was the logbook in the labor and de-
livery suite. Previous studies have been published from
these databases.7-9 Two observers independently re-
viewed all previous operative reports, medical, and nurs-
ing records. Data was collected for the following
variables: maternal age, gestational age, parity, previous
vaginal birth, previous VBAC, interval between the pre-
vious cesarean delivery and the subsequent delivery, in-
dication for the previous cesarean delivery, type of
closure of the previous low transverse uterine incision,
date of delivery, birth weight, use of oxytocin for aug-
mentation of labor, use of epidural anesthesia, modified
Bishop’s score before induction of labor, method of in-
duction, complete uterine rupture, and scar dehiscence
noted at the time of cesarean. Uterine rupture was de-
fined as a defect that involved the entire thickness of
the uterine wall, including the overlying peritoneum,
with extrusion of intrauterine contents into the perito-
neal cavity at the time of emergency cesarean or laparot-
omy.10
In our center, labor induction in patients with a previ-
ous cesarean and a favorable cervix (defined by a modi-
fied Bishop’s score R6 or a cervix dilatation R2 cm)
was done by amniotomy followed with oxytocin infu-
sion (1 mIU/min increased by 1 to 2 mIU/min every
20 to 30 minutes) when needed. When the fetal station
was considered too high to safely perform amniotomy,
1645
oxytocin infusion was started before artificial amnioto-
my. For patients with an unfavorable cervix, transcervical
extra-amniotic Foley catheters (Foley #18, with 50 mL of
sterile water in the balloon) were the method of choice for
cervical ripening before labor induction. Patients were
asked to arrive the evening before the induction, and
the Foley catheter was placed into the cervix. The follow-
ing morning (approximately 12 hours later), labor induc-
tion was started with amniotomy, and oxytocin was
added as needed. Patients with premature rupture of
membranes without spontaneous labor underwent labor
induction using intravenous oxytocin, regardless of the
cervical status.
The modified Bishop’s score is calculated based on 3
parameters: cervical dilatation (0 to 6 points), efface-
ment (0 to 3 points), and fetal station (0 to 3 points).3
In the present study, the score was calculated from the
first vaginal exam before labor induction, or any method
of cervical ripening. Patients were divided into 4 groups
based on modified Bishop’s score: 0 to 2, 3 to 5, 6 to 8,
and 9 to12.
The rates of vaginal delivery and uterine rupture were
compared between the groups. Differences between
groups were assessed through proportion comparisons
using the Pearson chi-square test or the Fisher exact test.
Logistic regression analysis was performed to adjust for
confounding variables, including maternal age R35
years old, gestational age, year of delivery, diabetes, in-
dication for the previous cesarean as a categorical vari-
able, more than one cesarean delivery, single-layer
closure of the previous lower transverse uterine segment
incision, interdelivery interval %24 months, cervical rip-
ening with transcervical Foley catheter, cervical ripening
with prostaglandins, epidural anesthesia, oxytocin use,
previous VBAC, previous vaginal delivery, birth weight
R4000 g, and modified Bishop’s score R6. Comparison
of means was performed using one-way analysis of var-
iance. Comparison of medians was performed using
Kruskal-Wallis test. Statistical analysis was performed
using SPSS 10.0 (SPSS, Inc, Chicago, Ill). P ! .05
was considered statistically significant. The Institutional
Review Board of our institution approved the project.
Results
From January 1988 to December 2002, 2493 patients
with a live singleton fetus at more than 24 weeks’ gesta-
tion underwent a TOL after a low-transverse cesarean
delivery. Out of 686 patients who underwent an induc-
tion of labor, 685 had a modified Bishop’s score avail-
able before the induction of labor; 187 (27.3%) from
0 to 2, 276 (40.3%) from 3 to 5, 189 (27.6%) from 6
to 8, and 33 (4.8%) from 9 to 11. Two hundred sixty-
nine patients (39.3%) underwent cervical ripening
with a transcervical Foley catheter (255) or intravaginal
1646 Bujold et al

Table I Characteristics of parturients

Modified Bishop’s score 0 to 2 (n = 187) 3 to 5 (n = 276) 6 to 8 (n = 189) 9 to 11 (n = 33) P value
Maternal age (y)* 31.1 G 4.4 31.2 G 4.6 30.8 G 5.0 31.4 G 4.1 NS
Gestational age (wk)* 39.3 G 2.1 39.5 G 2.1 39.6 G 1.7 39.6 G 1.2 NS
Birth weight (g)* 3283 G 638 3469 G 567 3504 G 565 3497 G 561 .001
Previous vaginal delivery 42 (22.5%) 85 (30.8%) 91 (48.1%) 18 (54.5%) ! .001
Previous cesarean for dystocia 75 (40.1%) 128 (46.4%) 73 (38.6%) 10 (30.3%) NS
More than 1 previous cesareany 5 (2.7%) 9 (3.3%) 7 (3.7%) 0 NS
Single-layer closure 58/163 (35.6%) 98/254 (38.6%) 48/174 (27.6%) 5/27 (15.6%) .01
Interdelivery interval (mo)* 48 G 31 50 G 29 56 G 37 43 G 19 .04
Cervical ripening with 145 (77.5%) 97 (35.1%) 13 (6.9%) 0 ! .001
Foley catheter
Cervical ripening with 9 (4.8%) 4 (1.4%) 0 0 .004
prostaglandins
Use of oxytocin 172 (92.0%) 261 (94.6%) 173 (91.5%) 27 (81.8%) NS
Epidural anesthesia 157 (85.5%) 206 (74.6%) 135 (71.4%) 19 (57.6%) .001
* Mean G standard deviation.

Table II Reasons for induction

Modified Bishop’s score 0 to 2 (n = 187) 3 to 5 (n = 276) 6 to 8 (n = 189) 9 to 11 (n = 33) P value
Hypertensive disorder 40 (21.4%) 34 (36.2%) 19 (10.1%) 1 (3.0%) ! .01
Insulin requiring diabetes 15 (8.0%) 18 (6.5%) 21 (11.1%) 1 (3.0%) NS
Other maternal indication 6 (3.2%) 5 (1.8%) 9 (4.8%) 4 (12.1%) .01
R41 weeks’ gestation 53 (28.3%) 101 (36.6%) 64 (33.9%) 11 (33.3%) NS
Premature rupture 13 (7.0%) 46 (16.7%) 19 (10.1%) 2 (6.1%) ! .01
of membranes
Fetal indication 41 (21.9%) 41 (14.9%) 32 (16.9%) 2 (6.1%) NS
Logistic and/or social 19 (10.2%) 31 (11.2%) 25 (13.2%) 12 (36.4%) ! .001
NS, Nonsignificant.

prostaglandins (14), including 6 patients who received
intravaginal dinoprostone, and 8 who received intrava-
ginal prostaglandin E2 gel. No patients received miso-
prostol for labor induction.
Comparison of demographics and obstetric data are
presented in Table I. Patients with modified Bishop’s
score between 0 to 2 and 3 to 5 were more likely to have
smaller neonates, a single-layer closure of their previous
uterine incision, cervical ripening, and epidural analge-
sia, but less likely to have a previous vaginal delivery.
Moreover, they were more likely to have their labor in-
duced for hypertensive disorders, but less likely for so-
cial/logistic reasons (Table II).
There was a significant difference in the rate of suc-
cessful VBAC between the 4 groups, with a direct corre-
lation between the score and the rate of successful
VBAC (Figure 1). These differences remained significant
between the first and second, the second and the third,
and between the third and the fourth group (P ! .05).
A similar relationship was found in patients with only
1 previous cesarean and no previous vaginal delivery
(71/140 [50.7%] vs 99/185 [53.5%] vs 70/96 [72.9%] vs
14/15 [93.3%], P ! .001).
Using step-wise regression analysis to adjust for con-
founding variable, the odds ratio for successful VBAC
was 2.07 (95% CI 1.28-3.35) in patients with a modified
Bishop’s score R6 (Table III). Previous vaginal delivery
and previous VBAC were also associated with a higher
rate of successful VBAC, while a previous cesarean for
dystocia in the first stage of labor, cervical ripening with
Foley catheter, and a birth weight R4000 g were associ-
ated with a lower rate of successful VBAC.
Patients with modified Bishop’s score between 0 to 2
and 3 to 5 were more likely to have a cesarean delivery
for both dystocia (59 [31.6%] vs 69 [25.0%] vs 24
[12.7%] vs 1 [3.0%], P ! .001) and fetal indications
(20 [10.7%] vs 29 [10.5%] vs 9 [4.8%] vs 0, P = .03).
In each group, more than 60% of the cesarean deliveries
were performed at a cervical dilatation of 4 cm or more.
Both the median 5-minute Apgar scores (9 [4, 10] vs 9 [1,
10] vs 9 [7,10] vs 9 [8,10], P = .03) and the rate of 5-min-
ute Apgar scores less than 7 (7 [3.7%] vs 7 [2.5%] vs 0 vs
0, P = .05) were statistically different between the
groups.
The rate of uterine rupture for each group is shown in
Figure 2, from 2.1% in patients with an initial score of
Bujold et al 1647

Figure 1 Rates of successful VBAC according to the Figure 2 Rates of symptomatic uterine rupture according to
modified Bishop’s score before the induction. The rate of the modified Bishop’s score before the induction. There were
successful VBAC was significantly different (P ! .001). no statistical differences in the rate of uterine rupture between
groups (P = .48).

Table III Multiple logistic regression with step-wise for

successful VBAC already been validated in a non-VBAC population as ex-
Odds ratio 95% CI P value
cellent predictor of obstetrical outcomes.3 These results
are consistent with those of McNally et al, who studied
Previous vaginal delivery 2.69 1.41e5.13 .003 103 patients who underwent an induction of labor after
Previous vaginal 3.32 1.35e8.13 .009
a previous cesarean delivery.11 They demonstrated that
birth after cesarean
cervical effacement before the induction of labor was as-
Indication for the previous
cesarean* sociated with successful vaginal delivery.11 Moreover, in
Dystocia in the first 0.50 0.34e0.74 .001 the same study, the 2 cases of uterine ruptures occurred
stage of labor in the subgroup of 24 women whose cervixes were de-
Dystocia in the second 0.97 0.50e1.88 .968 scribed as being uneffaced at the time of induction. Nei-
stage of labor ther of these 2 patients received prostaglandins. In
Cervical ripening 0.60 0.40e0.89 .011 another study including 5022 patients undergoing
with Foley catheter a TOL after a previous cesarean, Flamm et al reported
Birth weight O4000 g 0.52 0.32e0.85 .009 a significant correlation between both cervical efface-
Modified Bishop’s 2.07 1.28e3.35 .003 ment and cervical dilation at the time of admission
score R6
and successful VBAC.12
* Compared with cesarean performed for fetal indication. In addition to an increased rate of failed TOL, induc-
tion of labor has been associated with an increased risk
of uterine rupture in patients with a previous cesarean
0 to 2, to 0% in the patients with a score of 9 to 11. Al- delivery.13 Moreover, 2 studies, including 13,115 and
though the rate of uterine rupture decreased with mod- 2119 patients, respectively, who underwent a trial of la-
ified Bishop’s score, this difference was not statistically bor after a previous cesarean, reported the risk of uter-
significant. The rate of uterine rupture in patients with ine rupture to be even higher when induction of labor
previous cervical ripening using a Foley catheter or was attempted with the use of prostaglandins when com-
prostaglandins was 1.9% (5/269) compared with 1.2% pared with other methods, or when no cervical ripening
(5/417) in patients without previous cervical ripening was performed.14,15 However, the role of the cervical
(P = .52). Consistent with our previous publications,7,9 status before labor induction was not taken into ac-
an interdelivery interval less than 24 months (4.0% vs count. Theoretically, in all probability, prostaglandins
0.9%, P = .02) and a single-layer closure of the previous were used in patients with unfavorable cervix. It is diffi-
cesarean (3.3% vs 0.7%, P = .04) remained associated cult to separate the independent effect of cervical status
with a higher rate of uterine rupture in this subpopula- and the effect of prostaglandins on the rate of uterine
tion undergoing an induction of labor. rupture, unless information about cervical status of the
patients had been obtained. In fact, 2 other studies, in-
cluding 5022 and 382 patients, respectively, who under-
Comment went a trial of labor after a previous cesarean, did not
find an association between the use of prostaglandins
In this study, cervical status before labor induction was and uterine rupture.16,17 It is noteworthy that (1) unfa-
a significant and independent factor associated with the vorable cervical status has been associated with pro-
successful VBAC. As method of evaluation of cervical longed labor and high intrauterine pressure,18 and (2) in
status, we used the modified Bishop’s score, which has addition, prolonged dystocia is a risk factor for uterine
1648
rupture.19,20 Therefore, cervical status before labor in-
duction could be an important confounding factor re-
lated to uterine rupture.
Although not statistically significant, we found
a trend towards a higher rate of uterine rupture in pa-
tients with a lower modified Bishop’s score before labor
induction. This may be secondary to a small sample size
because approximately 2000 patients would be necessary
to detect a 4-fold increase in uterine rupture rate from
0.5% to 2%. In our series, only 14 patients received
prostaglandins for cervical ripening and, thus, we are
unable to draw any conclusions about the use of prosta-
glandins and uterine rupture.
The present study shows that patients with a favor-
able cervical status before labor induction have higher
chances to achieve a successful VBAC. Moreover, it sug-
gests that modified Bishop’s score is a potential con-
founding factor for obstetric outcomes that should be
considered in future studies in VBAC population. How-
ever, our study has some limitations. Although we
found statistically significant differences, our study is
limited by the lack of data on mid-term and long-term
maternal and neonatal morbidities. Because of the natu-
ral low incidence of uterine rupture, this study does not
have the power to detect significant differences between
the groups.
In conclusion, a history of a previous low transverse
cesarean section should not be a contraindication to an
induction of labor. However, in patients with a modified
Bishop’s score lower than 6, the rate of successful VBAC
is lower, especially in patients with no previous vaginal
delivery (approximately 50%), while patients with
a modified Bishop’s score R6 had a rate of successful
VBAC greater than 80% and a rate of uterine rupture
lower than 1.0%. In addition, (1) an interdelivery inter-
val and a single-layer closure of the previous uterine in-
cision remain important factors associated with uterine
rupture in this subgroup of patients undergoing an in-
duction of labor, and (2) a previous cesarean for dysto-
cia in the first stage of labor and absence of previous
vaginal delivery remain associated with a higher rate
of failed VBAC. Because a failed TOL has previously
been associated with a higher rate of severe maternal
complications when compared with elective repeat ce-
sarean,6 we believe that in the selected group of patients
with a previous cesarean delivery, no previous vaginal
delivery, and a modified Bishop’s score !6, elective re-
peat cesarean should be considered as a reasonable op-
tion to TOL if delivery is indicated.
Bujold et al
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