CLINICAL OBSTETRICS AND GYNECOLOGY

Volume 49, Number 3, 564572

r 2006, Lippincott Williams & Wilkins

Preinduction Cervical
Assessment
KERI A. BAACKE, MD and RODNEY K. EDWARDS, MD
Department of Obstetrics and Gynecology, University of Florida
College of Medicine, Gainesville, Florida
Abstract: The rate of labor induction is increasing in
the United States. Methods for quantifying cervical
factors have been developed to identify patients who
may benefit from cervical ripening before induction.
The first cervical scoring systems used digital
examination. More recently, cervical ultrasound
and testing for the presence of fetal fibonectin have
been suggested to evaluate cervical readiness for
labor induction, but neither of these methods
provides a significant improvement over digital
examination. The Bishop score, the most widely
used digital examination scoring system, still is
the most cost effective and accurate method of
evaluating the cervix before labor induction.
Key words: labor induction, cervical assessment,
cervical examination, Bishop score, cervical
ultrasound, fetal fibronectin

Historical Overview
1

Introduction
The rate of labor induction, for medical
and elective reasons, is increasing in the
United States. Obstetricians are well
aware that various cervical attributes
predict the progress and success of labor
induction. These attributes have been
described and quantified into several
scoring systems to select candidates for
Correspondence: Keri A. Baacke, MD, Department of
Obstetrics and Gynecology, University of Florida
College of Medicine, PO Box 100294, Gainesville,
Florida 32610-0294. E-mail: edwardsr@obgyn.ufl.edu
CLINICAL OBSTETRICS AND GYNECOLOGY

564

induction who have a higher likelihood

of successful vaginal delivery. These
scoring systems also have allowed for
identification of patients who may
benefit from cervical ripening before
labor induction.
This review will provide a historical
overview of the methods used to quantify
cervical readiness for labor and discuss
the evaluations of these scoring systems.
In addition, we will review recent studies
evaluating newer, more objective methods of cervical scoring, including fetal
fibronectin and ultrasound assessments
of the cervix.

In 1930, Calkins et al sought to identify

factors that could predict the length of
labor. They determined that patients
with previous deliveries had shorter
labors than nulliparous patients. They
further found that factors previously felt
to be prognostic of long labors, such as
obesity, nulliparity in the older gravida,
small pelvis, and large fetus, had no
association with the length of labor.
Calkins then published the first description of cervical assessment scoring to
more accurately predict the length of
VOLUME 49

NUMBER 3

SEPTEMBER 2006

Preinduction Cervical Assessment

labor.2 His scoring system considered the
intensity of contractions and the consistency, wall thickness and canal length of
the cervix, rated on a sale of 1 to 5.
Later, Calkins proposed another scoring
system assessing cervical factors.3 Effacement was determined to be present or
absent. The presenting part was engaged
when at, or below, the ischial spines.
Consistency of the cervix was said to be a
2 if as soft, or softer, than ones lips
and a 3 if as firm, or firmer, than the
nasal ala. He noted that patients with
favorable characteristics of effacement,
engagement, and soft consistency, had
shorter labors. In most cases, Calkins
performed his cervical assessments
through rectal examinations.
In 1955, Cocks4 described cervices in
terms of 5 types. Types 1 and 2 cervices
were considered ripe. Type 1 cervices
were soft, effaced, and admitted 1 finger;
type 2 cervices also were soft and
admitted 1 finger but were not effaced.
Types 3 and 4 cervices were considered
unripe. Type 3 cervices were firm, not
effaced with a closed internal os. Type 4
cervices were firm with a closed os but
were effaced. Anomalous cervices were
categorized as type 5. The cervix also was
noted to have a sacral os if it was
directed posteriorly. Cocks noted that
patients presenting with unripe cervices
were more likely to have operative
deliveries (either forceps or cesarean),
and patients with a sacral os were more
likely to have cesarean deliveries.
Dutton5 evaluated this classification
scheme in 1958 by analyzing 274 cases
of labor induction by membrane rupture.
In that series, 95% of type 1, 80% of
type 2, 65% of type 4, and 50% of types
3, 5 or those with a sacral os delivered
within 72 hours. He concluded that using
this method of cervical evaluation would
be helpful in selecting appropriate
candidates for labor induction.
In 1962, a study by Friedman and
Sachtleben6 evaluated the impact of

565

initial cervical characteristics on the

separate stages of labor, rather than the
induction to delivery interval. He found
that an initial cervical dilation of greater
than 2 cm correlated with a shorter latent
phase.
These early studies sought to describe
the importance of cervical characteristics
as predictors for successful labor induction. These same characteristics of
cervical dilation, effacement, position,
consistency, and station would later
form the basis for cervical scoring
methods used today.

Development of Cervical
Scoring Methods
Before the 1950s, labor induction could
only be achieved through amniotomy.
The availability of intravenous oxytocin
in the early 1950s led to an increased
enthusiasm for labor induction. Bishop7
reported on 1000 cases of elective induction of labor performed at a single
hospital. His observations noted that
cervical dilation, cervical effacement,
and station of the presenting part correlated with the length of labor in the
multiparous patient but not in the
nulliparous patient. He further noted
that the labor lasted more than 8 hours
in 40% of the nulliparas, regardless of
the initial condition of the cervix. On the
basis of these findings, he concluded that
elective induction of labor using intravenous oxytocin administration and amniotomy was an acceptable procedure in
certain selected patients. These patients
should meet certain criteria which included multiparity, cervical dilation of at
least 3 cm, cervical effacement of at least
60%, and the presenting part being at
minus 1 station or lower. Bishop further
stated that rectal examination of the
cervix was not a satisfactory method
to evaluate these factors. Subsequently,

566

Baacke and Edwards

TABLE 1.

The Bishop Score for Assessing Favorability for

Induction of Labor
Score

Factor

Dilation (cm)
Effacement (%)
Station
Consistency
Position

0
0-30
3
Firm
Posterior

1-2
40-50
2
Medium
Mid

3-4
60-70
1 or 0
Soft
Anterior

5-6
80
+ 1 or + 2

investigators used vaginal, rather than

rectal, examination of the cervix.
In 1964, Bishop8 described a pelvic
score, now known as the Bishop score,
which determined a patients suitability
for elective labor induction. This scoring
system was based on the cervical factors
previously shown to correlate with
successful labor induction (Table 1). He
found that a score of 9 or greater
resulted in a safe and uniformly successful labor induction. Elective labor induction and applicability of his scoring
system, he stressed, was only appropriate
in parous patients at term with an
uncomplicated pregnancy and with a
fetus in cephalic presentation. Since
Bishops original development of the
pelvic score, it has been used for cervical
assessment in any patient where labor

induction is being considered, not only

for term, multiparous patients who
are candidates for elective induction.
Despite many proposed modifications,
the original Bishop score still is most
commonly used.
One year before Bishop described his
pelvic score, Fields,9 at the meeting of
the Obstetrical Society of Philadelphia,
presented a similar scoring system. Fields
considered both cervical factors and
gestational age, estimated fetal weight,
the patients attitude toward the induction, the presence of contractions and
increase in amount of vaginal discharge
(Table 2). A score of 16 or greater was
considered favorable, except when the
patient was nulliparous or the fetus
was in breech presentation, when a score
of 18 or greater would be considered

TABLE 2. The Fields System for Rating Readiness for Induction

Score
Factor

Timing of induction
Versus EDC (wk)
Attitude toward induction
Estimated fetal weight (g)
Uterine tone on palpation
Softness of cervix
Effacement (%)
Position (axis) of cervix
Station of presenting part (cm)
Dilation (cm)
Recent vaginal discharge

Uncertain or >3 prior

Objects or fears
<2500
Flaccid
Firm
<80
Posterior
2 or higher
0-1
No change

1-3 prior
Hesitates, accepts
Uncertain
Some tone
Somewhat soft
80
45 degrees to vaginal axis
1 to 0
2-3
Increased

Within 1
Enthusiastic
>2500
Firm cxn
Soft
>80
Toward vulva
+ 1 or lower
>3
Blood-tinged

cxn indicates contraction; EDC, estimated date of confinement.

Preinduction Cervical Assessment

TABLE 3.

567

The Burnett Modification of the Bishop Score

Score

Factor

Dilation (cm)
Station
Position
Effacement (cm)
Consistency

<1.5
2 or higher
Posterior
1.5 or more
Firm

1.5-3
1
Mid
Intermediate
Intermediate

>3
0 or lower
Anterior
0.5 or less
Soft

favorable. Fields9 studied his scoring

system prospectively and noted that a
score of 10 or less resulted in a doubling
of the complication rate, an increase in
the average duration of labor and an
increase in the operative delivery rate.

Modifications of the Bishop

Score
In an effort to increase predictability of
successful induction and decrease associated morbidity, several modifications
have been proposed to Bishops original
pelvic scoring system. Burnett10 proposed what has become known as the
modified Bishop score (Table 3). This
scoring system gave each of Bishops
categories a maximum score of 2, for a
total maximum score of 10. He considered effacement in terms of centimeter in
length as opposed to percentage effaced.
Burnett also considered a prior term
birth and cephalic presentation to be

TABLE 4.

prerequisites for labor induction and

prior uterine surgery to be a contraindication. All patients with a score of 9
or 10 on his modified scale had a
duration of labor less than 4 hours; most
had labors of less than 2 hours. He
further noted that 90% of patients with
scores of 6 to 8 were delivered within 6
hours. The outcome of patients with
scores of less than 6 was unpredictable.
A different modification of the Bishop
score was proposed by Friedman and
colleagues.11,12 They evaluated 408 multiparas undergoing labor induction and
found that the latent phase, but not the
active phase, of the first stage of labor
was inversely related to the preinduction
cervical score. Furthermore, they found
that each of Bishops factors did not
influence the length of the latent phase in
equal proportions. Owing to these observations, they proposed that cervical
dilation be given twice the weight of
consistency, station, and effacement and
4 times the weight of position. Their

Weighted Bishop Score Proposed by Friedman and

Colleagues

Factor

Unweighted

Simple Weighting

Complete Weighting

Dilation
Effacement
Station
Consistency
Position
Range of scores

0-3
0-3
0-3
0-2
0-2
0-13

2
1
1
1
0
0-14

4
2
2
2
1
0-30

568

Baacke and Edwards

medical or obstetric indications using a
variety of different methods. They confirmed that the Bishop score, using
centimeters in length for cervical effacement, correlated well with the likelihood
of successful induction. Using multivariate linear regression analysis, they determined that cervical dilation was at least
twice as important as Bishops other
factors. On the basis of these findings,
the authors proposed another modification of Bishops scoring system (Table 5).
In their study, this simplified scoring
system predicted successful induction
and the Bishop score.
In 1976, Hughey and coworkers16
evaluated the comparative performance
of the scoring systems proposed by
Bishop,8
Fields, 9
Burnett,10
and
12
Friedman et al. They confirmed that
increasing scores predicted increasing
likelihood of successful induction in each
of these systems. These authors also
suggested adding separate modifiers
to the scoring system used in an attempt
to improve the systems prediction accuracy. These modifiers included adding
points for preeclampsia, each prior
delivery, and elective induction. Points
were subtracted for premature rupture of
membranes, postdates, or nulliparity. In
their study sample, these modifications
improved the accuracy of all scoring
systems.

proposal included 2 weighted scoring

systems on the basis of their findings
(Table 4). However, these authors did
note that the performance of neither of
their weighted scoring systems was clinically significantly better than the raw
Bishop score.
In the United Kingdom, a further
modification of Bishops score is used
extensively. The Calder score13 uses
length of cervix in centimeters rather
than percentage effaced and measures
station in terms of centimeters rather
than using Bishops original assessment
based on thirds of the pelvis. Finally, the
anterior position of the cervix would
receive the same score as a midposition
cervical score in the Calder modification.

Evaluation of the Bishop

Score
14

In 1977, Harrison et al evaluated the

Bishop scores of patients at 36 and again
at 40 weeks gestation, including both
parous and nulliparous patients. They
noted a significant increase in scores
during this last month of pregnancy and
also confirmed the association between
Bishop score and duration of induced
labor. In all, 87% of patients with scores
of 7 or greater delivered within 9 hours,
whereas those with scores of 4 or less
delivered within 9 hours only 44% of the
time. Harrison also evaluated each element of the Bishop score independently
and found dilation, effacement, and
station to be the most significant.
A study by Lange and colleagues15 in
1982 evaluated 1189 patients who underwent successful labor induction for

Ultrasound Assessment of the

Cervix
Recently, ultrasound assessment of cervical characteristics has been evaluated

TABLE 5. The Pelvic Score Proposed by Lange and Colleagues

Score
Factor

Multiply by

Dilation (cm)
Length (cm)
Station (cm)

0
3
3

1-2
2
2

3-4
1
1 or 0

>4
0
+ 1 or + 2

2
1
1

Preinduction Cervical Assessment

to predict successful labor induction. In
1986, OLeary and Ferrell17 proposed a
semiquantitative ultrasound scoring
system and evaluated this system against
the modified Bishop score. Their scoring
system used transabdominal ultrasound
to evaluate the thickness and contour of
the lower uterine segment, the length and
dilation of the cervix, and the station
of the presenting part. The authors
concluded that the ultrasound scoring
system correlated well with the modified
Bishop score. A favorable result using
either the ultrasound assessment or
digital examination was associated with
a high likelihood of successful labor
induction. However, no advantage of
ultrasound over digital assessment was
found.
In 1994, Boozarjomehri et al18 evaluated the association between transvaginal ultrasound assessment of the cervix
and outcome of labor induction. In their
study, they noted that the length of the
cervix was significantly associated with
the length of the latent phase of labor. It
was not, however, associated with the
total duration of labor. Cervical wedging
(dilation of the internal os with a closed
external os; today more commonly
known as funneling) was significantly
associated both with a shorter latent
phase and a shorter total duration of
labor. In their analysis, neither cervical
dilation nor effacement, as assessed by
digital examination, correlated with
duration of the latent phase or total
duration of labor. The authors concluded that ultrasound assessment of
cervical factors, such as wedging, may
be helpful in identifying patients who will
have a successful labor induction despite
an unfavorable digital examination.
A study by Ware and Raynor19 in
2000 compared transvaginal ultrasound
measurements of the cervix with Bishop
scores for predicting successful induction
at term. They noted that ultrasound
assessment is comparable to the Bishop

569

score in assessing cervical factors and

predicting the duration of labor.
However, only cervical length and
parity were independent predictors of
successful labor induction.
In 2001, Pandis and colleagues20
completed a multicenter study enrolling
240-term patients undergoing oxytocin
induction. They compared preinduction
ultrasound cervical assessment with
Bishop score for the ability to predict
delivery within 24 hours. The authors
noted a significant correlation between
ultrasound determined cervical length
and the induction to delivery interval.
They also observed that as the cervical
length decreased, the likelihood of vaginal delivery within 24 hours increased. In
their study, patients with a cervical
length of 18 mm or less achieved vaginal
delivery within 24 hours or less 98% of
the time. In contrast, 84% of patients
with cervical lengths greater than 31 mm
remained undelivered after 24 hours.
A significant association was noted
between the Bishop score and cervical
length. However, cervical length seemed
to be a better predictor, with a higher
sensitivity for successful labor induction.
Multivariate linear regression analysis
demonstrated independent contributions
of cervical length, parity, and the effacement portion of the Bishop score in the
prediction of successful delivery within
24 hours.
Chandra et al21 found different results
in 2001 when comparing the preinduction cervical length and the Bishop score
in the prediction of successful labor
induction. Their study consisted of 122
subjects who underwent both ultrasound
cervical assessment and digital cervical
examination before induction of labor.
They noted that only digital cervical
assessment predicted success with labor
induction. No ultrasound measurement
showed
a
significant
association
with successful labor induction, time to
delivery, or delivery within 24 hours.

570

Baacke and Edwards

Fetal Fibronectin as a
Predictor of Successful
Induction
Fetal fibronectin is part of the family of
ubiquitous glycoproteins found in high
concentrations in amniotic fluid and the
choriodecidual interface. Leakage of
fetal fibronectin into the vaginal secretions occurs before spontaneous labor.
Many studies have looked at the use of
fetal fibronectin as a predictor for
successful labor induction.
In 1995, Ahner et al22 first examined
the correlation of fetal fibronectin results
with successful labor induction. They
noted that fibronectin-positive patients
had shorter intervals to delivery than
fibronectin-negative patients. Using multivariate linear regression analysis, they
further noted that the fibronectin result
independently predicted delivery within
24 hours. Patients with both a low
Bishop score and a negative fibronectin
result were at highest risk for prolonged
length of induction and operative
delivery.
A study by Blanch and colleagues23 in
1996 sought to compare fetal fibronectin
results with the modified Bishop score
for prediction of successful labor induction. This study enrolled 103-term
patients, all of them underwent fetal
fibronectin swab collection followed by
Bishop scoring. The modified Bishop
score correlated well with fetal fibronectin results. Both Bishop score and
fibronectin result correlated with the
induction to delivery time and the length
of the latent phase. When nulliparous
and parous patients were analyzed separately, the fetal fibronectin result was
only significant in the nulliparous
patients. When analyzing the separate
cervical factors in the Bishop score, it
was noted that only cervical dilation
correlated with induction-to-delivery
time and the length of the latent
phase. This relationship, however, was

significant only in the multiparous

patients. The authors concluded that
fetal fibronectin testing, on a practical
level, is equivalent to the Bishop score.
In 2003, Reis et al24 compared digital
examination of the cervix, ultrasound
assessment of the cervix, and fetal
fibronectin to evaluate which of these
methods was useful in the prediction of
successful labor induction. These authors
found that obstetric history (previous
vaginal delivery) and digital examination
correlated best with successful labor
induction. In this study, the fetal fibronectin test showed poor predictability
with a likelihood ratio close to 1. The
relationship between transvaginal ultrasound assessments and successful induction also failed to reach statistical
significance. Using multivariate linear
regression analysis, these authors further
noted that the duration of labor independently was associated with previous
vaginal delivery and the digital examination. When patients had both a previous
vaginal delivery and a favorable digital
examination, the likelihood for delivery
within 24 hours was 93%. However, only
26% of patients with no previous vaginal
delivery and an unfavorable digital
examination delivered within 24 hours.
The authors also noted that dilation and
effacement elements of the Bishop score
were the only components significantly
associated with their outcome measures.
Roman and colleagues,25 in 2004,
studied 90 women with Bishop scores
of less than 5 undergoing labor induction. All women received fetal fibronectin levels and ultrasound assessments of
the cervix. They noted a significant
correlation between length of labor and
cervical dilation, parity, and Bishop
score. The length of labor was significantly longer when the cervix was
dilated 2 or less centimeters, in nulliparous women, and in women with cervical
lengths of greater than 27 mm by
ultrasound
assessment.
Ultrasound

Preinduction Cervical Assessment

determined cervical length, however,
was not more accurate than digitally
determined cervical dilation in predicting
the duration of labor.
Finally, in 2005, Rozenberg et al26
looked at 266 women requiring labor
induction between 34 and 41 weeks for
medical indications. Ultrasound assessment of the cervical length and Bishop
score were determined on each patient by
separate examiners and the time interval
from induction to delivery were noted.
Using univariable analysis, both Bishop
score and cervical length were found to
be predictive of induction time. However, when using multivariable analysis,
only the Bishop score was found to be
associated with induction to delivery
time. Their conclusion noted that once
the Bishop score is known, no further
benefit is derived from ultrasound assessment of the cervical length.

Summary
Systems of quantifying and scoring
cervical factors have been sought for
years in an attempt to predict the
duration of labor and to determine
which patients might successfully and
safely undergo induction of labor. The
earlier methods of cervical assessment
used physical attributes of the cervix to
classify favorable and unfavorable
cervices. These methods still are used in
general practice today. The most
prevalent scoring system is the one
developed by Bishop. This system and
its many modifications take into account
the cervical dilation, effacement, consistency, and position, and the station of
the presenting part. The Bishop score has
been evaluated in multiple studies, and
the factor with the strongest association
with successful induction seems to
be cervical dilation. Despite several
attempts at modification to improve
the predictability of the Bishop score,
none has been shown to be superior.

571

New methods of more objective

cervical assessment currently are being
investigated. Use of ultrasound and
biochemical findings, such as fetal
fibronectin, have been evaluated and
compared with the Bishop score. Most
evidence seems to show equivalence with
the Bishop score, but neither of these
newer methods consistently has been
shown to improve predictability of
successful induction. The Bishop score
still seems to be the most cost effective
and accurate method of predicting the
likelihood of successful labor induction
and the length of labor associated with
an induction.

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