A 38-year-old primigravida at 41 weeks of gestation presents to the labour ward for induction of labour. She has no contraindications to vaginal delivery. On examination, the cervix is 2 cm dilated, 80% effaced, firm in consistency, and the fetal head is at −2 station. The Bishop score is calculated as 6. She has a reactive fetal heart rate tracing. What is the most appropriate next step in the management of this patient?

Explanation

## Clinical Assessment **Key Point:** A Bishop score of 6 is considered unfavorable (score <8 indicates unfavorable cervix), meaning the cervix is not ready for labor induction with oxytocin alone. ## Bishop Score Interpretation | Bishop Score | Cervical Status | Management | | --- | --- | --- | | ≥8 | Favorable | Proceed with oxytocin induction | | <8 | Unfavorable | Cervical ripening required first | ## Management Algorithm ```mermaid flowchart TD A[Indication for induction of labour]:::outcome --> B{Bishop Score}:::decision B -->|≥8 Favorable| C[Oxytocin infusion]:::action B -->|<8 Unfavorable| D{Contraindications to vaginal delivery?}:::decision D -->|Yes| E[Cesarean section]:::urgent D -->|No| F[Cervical ripening agents]:::action F --> G[Reassess after 12-24 hours]:::decision G -->|Bishop ≥8| C G -->|Bishop <8| H[Consider alternative]:::action ``` **High-Yield:** Cervical ripening agents include: - **Prostaglandin analogues:** Misoprostol (25 mcg vaginally 3–6 hourly) or dinoprostone (0.5 mg intracervical) - **Mechanical methods:** Foley catheter balloon (18 Fr, 30 mL saline) for 12–24 hours **Clinical Pearl:** In this patient, the cervix is unfavorable (firm, 2 cm dilated, −2 station). Attempting oxytocin induction without ripening significantly increases the risk of failed induction and cesarean delivery. **Key Point:** After cervical ripening, reassess the Bishop score. If it becomes ≥8, proceed with oxytocin. If it remains <8 after 24 hours, consider alternative delivery methods or cesarean section. ## Why This Approach? 1. **Improves success:** Cervical ripening increases vaginal delivery rates by 25–30% 2. **Reduces complications:** Decreases uterine tachysystole and fetal distress 3. **Cost-effective:** Avoids unnecessary cesarean sections in primigravidas **Mnemonic:** **BISHOP** = Body mass index, Inducibility, Station, Cervical consistency, Cervical dilation, Position — remember that unfavorable cervix (score <8) needs ripening BEFORE oxytocin.