Bishop Scores... and warning about Cytotec

The Bishop Score is a method to help determine how favorable your body is for an induction. The less favorable, the more likely your induction will fail and thus lead to a cesarean birth. The more favorable your score is the more likely your induction will lead to a vaginal outcome. There are several reasons to induce. This is a question for you and your care provider. But determining how favorable you are is something you should know so you can make an informed decision regarding the likely outcome.

Points you earn / 0 / 1 / 2 / 3 /

Dilation (cm) / 0 / 1-2 / 3-4 / 5-6 /

Effacement (%) / 0-30 / 40-50 / 60-70 / 80 /

Station / -3 / -2 / -1/0 / +1/+2 /

Cervix / firm / medium / soft / /

Cervix Position /posterior/ meidan / anterior/ /

Ask the care provider these questions: How far dilated am i? How effaced? What station is the baby located? How does my cervix feel? Is it soft or firm? Did the provider upon the exam have to reach way back, making it uncomfortable to do the exam? Ask if your cervix is posterior or anterior. Then take that information and give each item a value based on the chart above. The add up your score. This gives you a predictive value for your inductions success.

A predictive value:

0-4 45-50% failure

5-9 10% failure

10-13 1% failure

Understanding your rate of success for induction is just gathering information in order for you to make an informed decision.

Doctors can improve your bishop score chemically. They can insert Cervidil into your cervix and it can often bring your dilation to 3 cm and increase your effacement. There are other methods like using a bulb syringe from a catheter to stretch the cervix to prepare you for an induction. There is another method that is considered quite controversial- misoprostil of Cytotec. I do not feel a women should consider this method until she read what the manufacturers say about its use for induction, "

Misoprostol , given as a 1/4 of a small tablet placed in the vagina.
Misoprostol is an ulcer drug that is contra-indicated in pregnant women, not approved for induction of labor, associated with increased uterine rupture and maternal/fetal/neonatal death.

Known complications include:

Uterine hyperstimulation / tetonic contractions -- less than 2 1/2 minutes between contractions or lasting longer than 75 seconds, can occur up to 12 hours later;

fetal distress or amniotic embolism due to prolonged hyperstim;

uterine rupture, hemorrhage, emergency hysterectomy, maternal or fetal death/disability,

neonatal brain damage at birth, admission to NICU, cerebral palsy.

And another authortiy on birth, Marsden Wagner writes, "

The June 1999 issue of the American Journal of Obstetrics and Gynecology published the article "Uterine rupture associated with the use of misoprostol in the gravid patient with a previous cesarean section." The data in this article are truly frightening. "Uterine rupture occurred in 5 of 89 patients with previous cesarean delivery who had labor induced with misoprostol. The uterine rupture rate for patients attempting vaginal birth after cesarean was significantly higher in those who received misoprostol, 5.6 percent, than in those who did not, 0.2 percent or 1 in 423, p=0.0001)." Furthermore, a medical records review turned up several more cases of uterine rupture associated with using Cytotec with VBAC not included in their calculations.

Be clear on what this says. Over five percent of women given Cytotec for VBAC had a ruptured uterus, a 28-fold increase over those who did not have Cytotec induction for VBAC. This is a truly shocking rate of uterine rupture. And one of the five women with uterine rupture ended up with a dead baby as a result of the rupture. Just in case you think this paper reports an aberration, the same issue of this journal has a second paper in which three of eighty-one women receiving Cytotec for a VBAC had uterine rupture--a still shocking rate of 3.7 percent. And one of the three babies died in the NICU after the rupture. Both these papers were retrospective which means that none of the women given Cytotec were part of a research project. Thus, none had received the protection of research subjects, including information on the experimental nature of the drug given to them.

So in these two papers, of 170 women given Cytotec for induction with VBAC, eight have lost their uterus and two lost a baby as well. It is my educated guess that to this day none of them has been told that they were given a drug for a purpose not approved by the FDA nor has been told their case is described in published papers saying this drug should not be used in this way. These women and babies paid a very big price because their practitioners were willing to use a very powerful drug before it has been approved by the FDA for this purpose and before it was adequately evaluated by prospective, controlled research.

Marsden Wagner MD, MSPH