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Commentary on “Pelvic Scoring for Elective Induction”

Noting a need for a “standardized, easily determined, and easily recorded plan for the selection of those patients most suitable for induction,” Bishop in this article put forward his proposal for a quantitative scoring system. He intended it specifically for elective induction; presumably, when induction was indicated for medical or obstetric reasons, the criteria would have to be modified or perhaps new criteria would be needed. Moreover, the author observed, “Owing to the unpredictability of the duration of labor in the nullipara, even in the presence of apparently favorable circumstances, induction of labor brings little advantage to either obstetrician or patient.” Thus, the system was intended only for parous women. On vaginal examination, Bishop rated dilatation, effacement, and station from 0 to 3 and consistency and position from 0 to 2. Thus, the individual score could be as high as 13 or as low as 0, and the author’s experience had shown that elective induction would be successful and safe at a value of 9 or more. With scores of 9 or more, he reported no failures of induction and an average duration of labor of “less than 4 hours.” The author suggested several possible uses of the score in addition to that of selecting candidates for elective labor induction: A high score some weeks before term might predict a risk of preterm labor, a low score at term might imply wrong dates or the possibility of postmaturity, and there could be some potential for use in scheduling repeat cesarean delivery operations. To evaluate reliability and predictability, the results of 500 vaginal examinations were related to the time until spontaneous onset of labor; in a scattergraph accompanying the article, score plotted against days to labor onset demonstrated a clear inverse relationship. Bishop used information gleaned from an extensive clinical experience as the basis for what would come to be known as the “Bishop score.” Unquestionably, however, this information was well known to virtually all obstetricians and had been known for many years, so why, one might ask, has the Bishop score become one of the most widely used clinical assessments in obstetrics? Bishop did not really “discover” anything that many before him had not known, but his unique contribution was to reduce these subjective assessments to quantitative (or perhaps semiquantitative) terms, thereby lending some objectivity and facilitating tabulations, comparisons, and statistical analysis (the latter often by inappropriate methods). Intended originally for multiparas being considered for elective induction, it is now used (in either its original form or one of many modifications) for women of all parity being assessed for mainly indicated induction, purely elective induction having largely fallen out of favor. Perhaps its widest use currently, at least as reflected in the literature, is as a means of evaluating various agents of promoting cervical “ripeness.” As further evidence of its influence, this three-page paper, with one author and no references, is the most frequently cited article ever published in Obstetrics & Gynecology. It has 554 citations as of January 1, 2002, according to the Institute for Scientific Information; although the article was published nearly 40 years ago, about a fifth of these citations occurred in the last 6 years, confirming its durable popularity. This kind of citation frequency probably places the Bishop article well within the top 0.1% of all articles published in any journal. Edward H. Bishop graduated from the University of Pennsylvania and spent much of his career at the Pennsylvania Hospital. He was a keen clinical observer, making important contributions in a variety of areas in clinical obstetrics, and he was one of the first to regard and treat the fetus as a patient. He was also unfailingly kind and courteous, and this, along with an aura of quiet competence, caused him to be worshiped as both a physician and a teacher. His physical mobility was somewhat limited by the residual of early poliomyelitis, but no one ever heard him complain about it, and he certainly did not allow it to handicap a productive career. In 1972, he moved to the University of North Carolina where he worked until retirement a decade later. He died in December 1995.