A 28-year-old primigravida at 41+2 weeks of gestation presents to the labor ward for induction of labor. Her antenatal course has been uncomplicated with normal fetal growth and reassuring CTG findings. On examination, the cervix is 2 cm dilated, 50% effaced, firm in consistency, and the fetal head is at -2 station. The Bishop score is calculated as 6. Which of the following is the most appropriate next step in management?

Explanation

## Clinical Assessment **Key Point:** A Bishop score of ≤6 indicates an unfavorable cervix and requires cervical ripening before labor induction can be attempted. ### Bishop Score Interpretation | Bishop Score | Cervical Status | Management | |---|---|---| | ≤6 | Unfavorable | Cervical ripening required | | 7–8 | Intermediate | May attempt ripening or induction | | ≥9 | Favorable | Proceed with oxytocin induction | **High-Yield:** In this case, the cervix is firm, minimally dilated, and only 50% effaced—all indicators of an unfavorable cervix. The Bishop score of 6 confirms this. ### Cervical Ripening Agents Misoprostol (a PGE₁ analogue) is the most commonly used pharmacological agent for cervical ripening in India and globally. The standard regimen is **25 mcg intravaginally every 3–6 hours**, with a maximum of 4–6 doses over 24 hours. **Clinical Pearl:** Misoprostol is preferred over dinoprostone (PGE₂) because it is: - Cheaper and more stable (no refrigeration required) - Easier to administer - Associated with lower rates of hyperstimulation when used at low doses ### Why Other Options Are Incorrect 1. **Cesarean section:** There is no indication for primary cesarean delivery. The patient has a reassuring CTG, normal fetal growth, and no obstetric contraindication to vaginal delivery. Cephalopelvic disproportion cannot be diagnosed without a trial of labor. 2. **ARM + oxytocin:** Artificial rupture of membranes in the setting of an unfavorable cervix significantly increases the risk of failed induction and necessitates cesarean delivery. ARM should only be performed once the cervix is favorable (Bishop ≥8) and labor has begun. 3. **Expectant management:** At 41+2 weeks, the patient is beyond term and at increased risk of stillbirth, meconium aspiration, and neonatal complications. Induction is indicated; expectant management is not appropriate. **Mnemonic — Cervical Ripening Agents: PGM** - **P**rostaglandins (misoprostol, dinoprostone) - **G**lyceryl trinitrate (mechanical alternative) - **M**echanical (Foley catheter, laminaria) [cite:Williams Obstetrics 26e Ch 21]