Ultrasound Obstet Gynecol 2014; 43: 3–10
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.13268
Editorial
Fetal macrosomia: a problem in need
of a policy
STUART CAMPBELL
Create Health Clinic, London, UK
(e-mail: profscampbell@hotmail.com)
Introduction
Fetal macrosomia is associated with increased risks for
the mother, including emergency Cesarean section (CS),
instrumental delivery, shoulder dystocia and trauma to the
birth canal, bladder, perineum and anal sphincter; for the
baby, complications include increased mortality, brachial
plexus or facial nerve injuries, fractures of the humerus
or clavicle and birth asphyxia1 – 7 . Fetal macrosomia now
is usually defined as a neonate with a birth weight above
4.5 kg2 – 4 and has a prevalence in developed countries
of 1.3–1.5% of all births. A gestational-age-dependent
definition, the 97th centile, is sometimes used and has
a similar prevalence. Other definitions, such as birth
weight > 4 kg (prevalence, 7%) or birth weight > 90th
centile5 , include many babies with a lower order of risk
for adverse outcome. The 4.5-kg limit is only appropriate
for term births and can be criticized for being rather
arbitrary; for example, the incidence of shoulder dystocia
rises steeply between birth weights of 4.0 and 4.25 kg6 ,
so 4.25 kg could legitimately be used as the cut-off.
However, the 4.5-kg limit defines unequivocally a high-
risk group of babies that requires accurate diagnosis and
intelligent management to minimize the risks to mother
and baby. Fetuses growing above the 97th centile during
the third trimester can also be regarded as macrosomic,
but, although at increased risk from metabolic problems7 ,
they do not contribute significantly to the classical injuries
associated with fetal macrosomia until term is reached.
Three per cent of all births and 5–10% of macrosomic
fetuses8 are associated with maternal diabetes and the
management of this subset will not be discussed in detail
in this Editorial. Women with diabetes or gestational
diabetes are usually identified prenatally and monitored
and cared for by a specialist team. Induction of labor
and elective CS is recommended according to individual
circumstances2 . Macrosomic fetuses of non-diabetic
women can be identified as being at risk by factors
such as maternal obesity and family history but are
generally unsuspected until the possibility of a big baby
is raised by antenatal clinical or ultrasound examination.
Management of this group of pregnant women has been
determined largely by two influential publications. In the
Copyright  2014 ISUOG. Published by John Wiley & Sons Ltd.
first, Rouse et al.9 performed a decision analysis on the
monetary costs of three different management policies,
i.e. management without ultrasound; ultrasound and
elective CS delivery for a predicted birth weight of 4.0 kg;
and ultrasound and CS delivery for a predicted birth
weight of 4.5 kg. On the basis of an ultrasound sensitivity
of 60% and specificity of 90% for prediction of a macro-
somic fetus, they calculated that in the USA the 4.5-kg
management policy would entail carrying out 3695 CSs
or spending an extra 8.7 million dollars for each brachial
plexus injury prevented in non-diabetic gestations. Their
conclusion was that, ‘for the 97% of women who are
non-diabetic, elective CS for ultrasonically diagnosed
macrosomia was economically unsound.’ This study was
quoted extensively in the second influential publication,
the American College of Obstetricians and Gynecologists
(ACOG) Practice Bulletin2 , which provided a detailed
quantification of the risks of macrosomia and recom-
mended clinical management when ultrasound predicted
this condition. The ACOG concluded that although the
diagnosis of fetal macrosomia was imprecise, prophylactic
CS ‘may be considered’ for suspected fetal macrosomia
with estimated fetal weights (EFW) ≥ 5.0 kg (i.e. 11
pounds) in women without diabetes. The implication, of
course, is that for weights < 5.0 kg, elective CS should
not be considered. This recommendation has since been
echoed by several authors8,10,11 . In the UK, the Royal
College of Obstetricians and Gynaecologists (RCOG), in
its Shoulder Dystocia Guideline in 201212 , refers to the
Rouse paper findings and notes the ACOG recommenda-
tions, but does not provide any management guidelines
for suspected macrosomia in non-diabetic women.
However, as the RCOG/National Institute for Health
and Care Excellence (NICE) guidelines on antenatal care
(2012)13 stipulate that ‘Ultrasound estimation of fetal
size for suspected large for gestational age unborn babies
should not be undertaken in a low risk population’ and
the RCOG/NICE guideline on CS14 does not list fetal
macrosomia amongst the indications for elective CS, the
view of RCOG/NICE on this subject is clear: elective CS
should not be performed for this indication.
Thus, while it is universally accepted that elective CS
can virtually eliminate shoulder dystocia and brachial
plexus injury without increasing maternal mortality,
the current mantra is that ultrasound prediction of
macrosomia is inaccurate and brachial plexus injuries are
rarely permanent, so justification fails both on clinical
and on monetary grounds. However, as the ACOG and
RCOG recommend elective CS in women with diabetes
with a predicted birth weight > 4.5 kg, they appear to be
acknowledging tacitly that ultrasound estimates of birth
weight are not valueless. The findings of the Rouse paper
have been challenged recently by Culligan et al.4 , who
carried out a similar decision analysis comparing current
EDITORIAL
4 Campbell
‘standard care’ with an ultrasound scan at 39 weeks and
elective CS for predicted birth weight ≥ 4.5 kg. This ana-
lysis included new longitudinal data on brachial plexus
injury to the newborn and also risks of maternal anal and
urinary incontinence. Their outcome measures included
the number of brachial injuries and cases of incontinence
averted, incremental monetary costs per 100 000 deliver-
ies, expected quality of life of the mother and child and the
‘quality adjusted years’ (QUALY) associated with each
of the two policies. They conclude that a policy whereby
primigravid patients in the USA have a 39-week scan to
estimate fetal weight followed by elective CS for predicted
birth weights ≥ 4.5 kg was cost effective. This paper has
had minimal impact on public health care policy, perhaps
because it was published in a urogynecological journal.
This Editorial will examine the issues surrounding the
debate over elective CS for fetal macrosomia and make
suggestions for a policy fit for the 21st century.
Risks of macrosomia
Fetal injury
Published graphs of neonatal mortality against birth
weight show a sharp rise in babies > 4.5 kg15,16 . While
this may in part be due to the association of macrosomia
with post-dates gestations and maternal diabetes, it also
reflects the high rate of emergency CS and instrumental
delivery and subsequent birth trauma in women who
labor with a large fetus. For babies weighing 4.5 kg
or more, the emergency CS rate is 45%9 and the
instrumental delivery rate 19%17 . Long-term damage
to the infant is most commonly discussed in relation to
shoulder dystocia. The average risk of shoulder dystocia
in the obstetric population is 1.4%, but when birth weight
is greater than 4500 g the risk varies from 9 to 24%2 .
The large study from California6 , which included 6238
infants with shoulder dystocia, put the risk at 14.3% for
non-diabetic infants weighing between 4500 and 4750 g
and 21.1% for infants weighing 4750–5000 g. The inci-
dence of shoulder dystocia in vacuum- or forceps-assisted
births was 23% for infants with birth weight between
4500 and 4750 g and 29% for those between 4750 and
5000 g. Similar findings were reported by Acker et al.18 .
Rates of shoulder dystocia in mid-forceps deliveries
of infants heavier than 4500 g have been reported to
be above 50%2 , so, barring extreme emergencies, CS
delivery should be performed for mid-pelvic arrest of
the fetus with suspected macrosomia. Induction of labor
is associated with a doubling of the risk of CS delivery
without reducing the risk of shoulder dystocia19,20 .
Obstetric brachial palsy injury (OBPI) is strongly associ-
ated with macrosomia and shoulder dystocia. The average
rate of OBPI in the obstetric population is 0.5–1.9/1000,
while for babies with a birth weight > 4.5 kg there is an
18–21-fold increased risk2 . Macrosomic compared with
non-macrosomic infants delivered after shoulder dystocia
are at a higher risk of OBPI. Rouse et al.9 , in their analysis,
estimated that 26% of babies with birth weights ≥ 4.5 kg
delivered following shoulder dystocia will have a brachial
Copyright  2014 ISUOG. Published by John Wiley & Sons Ltd.
plexus injury. Overall, the risk of OBPI for macrosomic
infants delivered vaginally is 4–8%2 . Raio et al.21 stressed
the importance of short maternal stature as an associated
risk factor in predicting birth injury. They calculated that
the number of CS deliveries required to prevent a single
case of permanent OBPI in fetuses predicted to be ≥ 4.5 kg
would be 30 in women shorter than 155 cm and 715 in
those taller than 180 cm. Gudmundsson et al.22 confirmed
this and constructed risk estimation curves based on birth
weight and maternal height.
The risk of permanent injury is frequently reported to
be about 10% among all cases of OBPI2 and Rouse et al.9
estimated for their cost analysis that the risk of permanent
injury from OBPI was only 6.7%. Most of these estimates
were based on short-term follow-up and few gave details
of the pediatric examinations. Subsequent to the Rouse
paper, two substantial longitudinal studies, each of over
60 infants with OBPI carried out in orthopedic surgery
and rehabilitative medicine departments, were published.
Waters23 , in an extremely detailed study, found that
only 16.7% of OBPI cases spontaneously resolved, 27%
were permanent and severe (arm useless throughout life)
and 56% were permanent and moderate (abduction and
rotation limited to < 30◦ ). Hoeksma et al.24 reported
that only 51% of OBPI children underwent complete
recovery because shoulder contractures with functional
deterioration developed in 30% of infants who had
apparently made a full neurological recovery. It should
also be noted that persistent OBPI is six times more
common when the birth weight is ≥ 4.0 kg compared with
< 4.0 kg6 . Culligan et al.4 in his cost analysis factored in
the data from the Waters study.
More serious are the other problems associated with
the birth of a large baby. The California study6 found
that birth injuries in general as well as birth asphyxia
were significantly more frequent in infants born following
labors complicated by shoulder dystocia. There was
also an association between neonatal length of stay and
‘non-normal’ neonate at discharge. Iffy et al.25 studied
retrospectively 316 fetal neurological injuries associated
with arrest of the shoulders, across the USA. He found
that as many as 64 (20%) children displayed manifesta-
tions of central nervous system (CNS) damage, such as
cerebral palsy, seizures and cognitive defects, 6 or more
months after their birth. They estimated that the risk of
irreversible fetal damage in cases of attempted vaginal
delivery exceeds 2.5% for fetuses ≥ 4.5 kg and 5% for
birth weights above 5 kg. It should be noted that these
asphyxia problems were only recorded in association
with shoulder dystocia. The overall risk of CNS problems
associated with macrosomia is likely to be higher.
Maternal injury
There is a strong correlation between macrosomia and
pelvic floor damage and the development of anal and
urinary stress incontinence and prolapse. Birth weight
> 4 kg imposes risk of perineal injury, especially third-
and fourth-degree tears due to larger head circumference
Ultrasound Obstet Gynecol 2014; 43: 3–10.
Editorial
(HC), prolonged labor and difficult delivery, especially if
instrumental birth is performed.
Anal incontinence represents a distressing social handi-
cap and vaginal delivery is now recognized as its principal
cause. Three large studies26 – 28 using multivariate regres-
sion models found that macrosomia was a strong
independent risk factor for anal sphincter damage. The
other consistent factor was assisted vaginal delivery,
especially with forceps. Even after safe delivery of the
head, shoulder dystocia – more common in macrosomic
infants – may contribute to perineal and anal sphincter
trauma. There is a strong association between anal
sphincter injury and maternal fecal incontinence. A
meta-analysis of five studies in which endoanal sono-
graphy was performed after vaginal birth found a 26.9%
incidence of anal sphincter defects, one third of which
were symptomatic29 . Culligan et al.4 calculated the
likelihood of chronic anal incontinence following third-
or fourth-degree anal sphincter disruption to be 23%,
but this seems high and a figure of 9–11% is more
likely30 – 32 . Anal incontinence has a significant negative
effect on sexuality, exercise, social activities and work
activities and is directly associated with depression33 .
A large baby is also likely to disrupt the fascial supports
of the pelvic floor and cause a stretch injury to the
pelvic and pudendal nerves, leading to vaginal prolapse.
Handa et al.30 followed up over a thousand women for a
longitudinal cohort study 5–10 years after first delivery.
Compared with elective CS delivery, spontaneous vaginal
birth was associated with a significantly greater odds
of stress incontinence and prolapse to or beyond the
hymen. Operative vaginal delivery significantly increased
the odds for urinary stress incontinence (odds ratio
(OR), 4.45), anal incontinence (OR, 2.22) and especially
prolapse (OR, 7.5). What was important was that CS
was protective even when performed in active labor up
to complete cervical dilatation.
Vaginal birth predisposes to genuine stress incontinence
(GSI). Urethral closure pressure and functional length
are reduced following vaginal delivery, but this does not
occur after CS34 . The association between a large fetus,
prolonged second stage and perineal nerve damage has
also been clearly demonstrated35 . Farrell et al.36 , in a
follow-up study of healthy primiparae, found urinary
incontinence rates at 6 months of 10% following CS,
22% following spontaneous vaginal delivery and 33%
following forceps delivery. CS at any stage was protective.
Viktrup et al.37 , in a prospective study, found that post-
partum GSI was independently related to birth weight,
episiotomy and HC. In a follow-up survey, Viktrup and
Lose38 reported a prevalence of GSI of 30%, 5 years after
first delivery. Like Handa et al.30 , they found CS birth to
significantly reduce the risk of GSI. Meyer et al.39 found
similar results with 21% of women having GSI persisting
after vaginal birth but only 3% following CS.
In summary, there is a strong relationship between the
delivery of a macrosomic fetus, instrumental delivery,
anal sphincter disruption and the development of anal and
urinary stress incontinence and uterovaginal prolapse.
Copyright  2014 ISUOG. Published by John Wiley & Sons Ltd.
5
What is also clear is that most of the serious effects for
both child and mother are related to vaginal birth and
that CS at any stage of labor up to full dilatation is largely
protective for these complications. With this knowledge
it has to be asked why the obstetrician proceeds to a
difficult delivery when a decision to perform CS would
avoid these problems.
Antenatal prediction of macrosomia
It is highly likely that the current laissez-faire attitude
towards management of the suspected macrosomic
fetus would be different if a very precise method of
estimating fetal weight were available. It is stated not
infrequently that ultrasound is no better than clinical
examination40 – 42 or the patient’s own estimation of the
weight of her baby43,44 . There is now, however, com-
pelling evidence that ultrasound is superior to all other
methods at the extremes of the birth-weight range45 – 47 ,
with, perhaps, the exception of magnetic resonance imag-
ing (MRI)48 . Therefore, ultrasound is the only practical
method with which to screen pregnant women for fetal
macrosomia. The almost universal practice is to put the
measurements of biparietal diameter (BPD), HC, abdomi-
nal circumference (AC) and femur length into a regression
model which calculates EFW. A few of the equations that
are currently used remove the BPD component (to remove
the bias caused by dolichocephaly) and a few use the alter-
native of the mean abdominal diameter (AD). Ultrasound
has a maximum random error of approximately 100 g/kg,
which means that weight predictions in grams for small
fetuses appear to be more clinically useful. Indeed, many
researchers have found ultrasound prediction of macro-
somia to be inaccurate and of little clinical value49,50 .
There are two principal components contributing to
inaccuracy in ultrasound predictions, i.e. the systematic
error, which is dependent on the appropriateness of
the prediction formula, and the random error, which is
dependent on the inherent inaccuracies of the technique
and can be lessened by taking repeated and multiple fetal
measurements51 and making certain that the sections of
the fetal anatomy have been obtained accurately. Other
factors that increase random error are maternal obesity,
oligohydramnios, poor-quality equipment and an inex-
perienced operator. In Dudley’s52 comparative analysis
of 11 different formulae, it is clear that the systematic
errors of the various formulae are close to the mean for
normal-weight fetuses but most underestimate the weight
of large and overestimate the weight of small fetuses.
What is also striking from Dudley’s analysis is that the
percentage random error for large fetuses is smaller than
that for normal or small fetuses, with 95% confidence
limits consistently just below 10%. Dudley’s findings were
confirmed by Melamed et al.51 , who compared 26 dif-
ferent formulae on 3705 fetal weight estimations within
3 days of birth. For fetuses ≥ 4.5 kg, the random error
was 10% or less in 21 formulae, with an overall mean of
8.1%. The systematic underestimation of birth weights in
this category was –6.2%. The authors postulated that a
Ultrasound Obstet Gynecol 2014; 43: 3–10.
6 Campbell
strategy of replacing the original coefficients of the models
by coefficients derived for the specific study population
could theoretically have reduced the systematic bias in the
macrosomic group. This makes it important to have a tar-
geted formula for fetuses over 4.5 kg, to reduce systematic
errors to a minimum53 . Most fetal weight prediction stud-
ies for macrosomia choose 4 kg and above as the definition
of macrosomia or select high-prevalence populations,
such as women with diabetes mellitus54 or who are
post-dates55 , thus improving the positive predictive value
(PPV) of the test. As demonstrated by Rouse et al.9 , a high
PPV is essential to reduce costs from unnecessary CSs.
If screening for the large-for-gestational age infant is
to be attempted, it might be a good option to undertake
a two-stage operation, i.e. a screening scan at around
32–34 weeks’ gestation to identify a high-risk group,
followed by a detailed scan at 39 weeks in those identified
as being large. The object of the earlier or triage scan
would be to achieve as high a sensitivity as possible so that
most large fetuses are in the screen-positive group. The aim
of the second diagnostic scan would be to achieve a high
predictive value so that the woman would know that her
chances of delivering a fetus weighing more than 4.5 kg
are high. The 39-week scan being performed on a high-
risk population with a higher prevalence of large fetuses
would therefore be more likely to achieve clinically useful
PPVs, especially if a targeted formula for macrosomia and
the latest ultrasound three-dimensional (3D) volumetric
studies or even MRI were utilized56 – 58 . Unlike MRI,
the disadvantage of 3D volumetric studies is that the
constraints of transducer size limit the region of interest
that can be examined, so the current idea is to include the
volume of a short cylinder rather than a two-dimensional
(2D) slice in the typical 2D EFW equation. For example,
recently Lindell et al.58 used a formula combining 2D
measurements of fetal head, abdomen and femur and 3D
volumetry of fetal abdomen and thigh to assess the weight
of 114 clinically and ultrasonically large-for-dates fetuses.
For fetuses > 4.5 kg (with the formula set at a cut-off of
4.3 kg), they were able to identify 93% of macrosomic
fetuses for a false-positive rate of 38%. This 2D/3D
formula was an improvement on existing 2D equations
for the prediction of macrosomia. At the moment it is a
time-consuming technique as volume measurements are
made offline, but, with the development of automated
volume estimation, 3D volumetry may add considerably
to the precision of sonographic weight estimates. Another
approach is to attempt to predict shoulder dystocia on
the premise that it is more likely to develop in fetuses
with disproportionately large abdominal girth. This is
particularly true of the fetus of the diabetic mother.
A paper in this issue of the Journal59 explores this
concept; although AC and EFW had better sensitivities
and specificities, an AD − BPD difference > 26 mm had a
high OR of 7.6 for predicting shoulder dystocia.
Another benefit of the early third-trimester scan would
be to provide an opportunity to identify and treat
women with abnormal glucose tolerance and address any
problems associated with obesity. The scan would also
Copyright  2014 ISUOG. Published by John Wiley & Sons Ltd.
reveal an increase in amniotic fluid volume, which is also
associated with macrosomia60 , and, at the other end of
the scale, any unexpectedly small fetuses.
Several authors have found AC measurement alone to
be as accurate as more complex formulae for predicting
fetal weight or macrosomia46,52,61,62 . While multiple-
parameter EFW would be ideal, the logistics of screening
every woman might favor the simple approach, especially
in low-risk settings. For example, in a study from a Dutch
primary care midwifery practice63 , routine AC measure-
ments performed between 27 and 33 weeks enabled the
detection of two thirds of cases of macrosomic fetuses
with a PPV of 23%. If all the scans had been performed
after 30 weeks, the results would likely have improved.
Several authors have reported that AC is effective in iden-
tifying the large fetus in the early third trimester, although
many have used a birth weight of 4 kg as the definition of
macrosomia. Pilalis et al.64 found that screening with AC
alone between 30 and 34 weeks identified 70% of babies
with birth weight over 4 kg for a screen-positive rate of
25%. A full EFW with four parameters contributed only
a 3% improvement in the detection rate. Lindell et al.65 ,
using a multiparameter equation, reported sensitivity,
specificity and predictive values of screening in an
unselected Swedish population at 32–34 weeks. Using a
z-score of 0.5 as the cut-off, they achieved a sensitivity
of 88% and specificity of 73% for the prediction of birth
weight > 4.5 kg. Although the PPV was only 14% it is
likely that this would rise considerably if the 27% of
women identified as high risk were rescanned at 39 weeks.
The sensitivities and specificities chosen by Rouse
et al.9 and Culligan et al.4 to input into their decision
analyses were almost identical but were based mostly on
studies of diabetic or post-dates gestations or babies with
birth weights over 4 kg, and are therefore not relevant to
the screening of an unselected population to detect birth
weights over 4.5 kg. Furthermore, Rouse et al.9 chose a
very low PPV for ultrasound and calculated the cost of a
seven-fold excess of CSs attributable to this. It should be
remembered that most equations show that ultrasound
underestimates the birth weight of macrosomic fetuses. If
the systematic error were minimal, with 95% confidence
limits of 10% for random errors, nearly all predictions
would be between 4 and 5 kg. Shoulder dystocia rises
sharply between 4 and 4.5 kg which means that an
overestimate would still identify a high-risk population.
This is not so for fetal weight predictions for a 4-kg birth
weight where many low-risk fetuses would be included in
the ultrasound estimate.
In summary, ultrasound estimations of fetal weight to
predict macrosomia, although imprecise, are not valueless.
It requires, however, a targeted approach and a realization
of the seriousness of the condition and the importance of
making predictions as accurate as possible.
Patient autonomy
Before considering factors affecting the delivery of
the macrosomic fetus, it is worth examining recent
Ultrasound Obstet Gynecol 2014; 43: 3–10.
Editorial
developments in relation to maternal autonomy and birth
in normal gestation. At the turn of this century, there was
an intense debate in the literature as to whether elective
CS should be performed at a woman’s request in the
absence of an obstetric indication. What is clear is that
there was no dispute that elective CS and vaginal birth
were equally safe in terms of mortality for the mother,
but that both had different types of complications, of
which prospective parents should be made aware66 . In
a widely quoted study67 , a postal survey asked British
obstetricians to consider whether they or their partners
would choose either elective CS or vaginal delivery if
they had a hypothetical singleton pregnancy with cephalic
presentation at term. The response rate was 73%. Overall,
17% chose CS, with 31% of female obstetricians choosing
this option over vaginal delivery. Among the reasons given
for choosing elective CS was fear of long term sequelae
of vaginal birth, specifically stress incontinence and anal
sphincter damage, fear of perineal damage from vaginal
birth and its effect on sexual function and fear of damage
to the baby. A Lancet editorial in 199768 stated: ‘The trend
for use of CS coupled with greater emphasis on individual
autonomy in medical decision making has clearly
progressed too far for a return to paternalistic directions
to women on how they should give birth. Instead the
emphasis should be on comparisons of the implications of
vaginal versus CS delivery. The uptake of CS in women
made aware of such information will clearly be more
appropriate than any of the current ‘‘desirable targets’’.’
The ACOG69 in 2003 published a Committee Opinion
stating: ‘If taken in a vacuum the principle of patient
autonomy would lend support to the permissibility of
elective CS delivery in a normal pregnancy after adequate
informed consent.’ These sentiments were challenged in
combative papers by Bewley and Cockburn70,71 , who
argued that the sizeable minority of female obstetricians
choosing elective CS as a first option ‘may be biased by
their exposure to the complications of childbirth.’ Their
response to a CS delivery on maternal request included
referral to a psychiatrist, a mandatory second opinion and
a series of ‘checks and hurdles’ in a continuing dialogue
with the woman which might be mistaken for coercion.
Subsequently, a similar USA survey72 confirmed a high
(21%) preference for maternal request among American
obstetricians, listing urinary and anal incontinence and
concern for fetal death or injury as reasons. A further
survey in New Zealand73 found that 11% of midwives,
21% of obstetricians, 42% of urogynecologists and 41%
of colorectal surgeons preferred the option of elective CS.
What is particularly relevant to this Editorial is
that when obstetricians in the original survey were
presented with the scenario that the baby was in cephalic
presentation but the EFW was > 4.5 kg, 66% of male
and 60% of female obstetricians chose elective CS. Note
that male obstetricians had gone from 8% to 66% in
favor of elective CS for their partners when informed
of the fact that the fetus was macrosomic. The Lancet
paper concludes with the question: ‘In this era of patient
choice should information regarding the potential benefits
Copyright  2014 ISUOG. Published by John Wiley & Sons Ltd.
7
of elective CS delivery be given to all women?’ With
suspected fetal macrosomia we are dealing not with a
normal situation but with one in which the predicted
weight of the fetus is 4.5 kg or more. When presented with
this scenario, most obstetricians would choose elective CS
for themselves or their partners, so surely it is unthinkable
that any obstetrician armed with this knowledge would
not counsel his (or her) patient on the risks of vaginal
birth associated with macrosomia and at least offer a
choice of elective CS?
Balance of risks
Most women want a vaginal birth. Turner et al.73 reported
that only 2% of women in their survey of normal
primiparous women wanted an elective CS, but women
know instinctively about the risks of birth injury and to
their pelvic floor if their baby is large. If you want proof,
just look at the expression of concern on the mother’s face
when she is told she is having a big baby. Nevertheless, the
instinct of the mother will be towards having a vaginal
birth and it will be up to the obstetrician to provide
objective information regarding the balance of risks so
that she and her partner can make an informed choice
about the method of delivery. The risks of elective CS,
such as neonatal respiratory distress, tachypnea, repeat CS
and placenta accreta, which form part of the discussion
over maternal request for CS, pale into insignificance
when the risks of vaginal birth with a macrosomic fetus
are now on the other side of the equation. The maternal
mortality rate with elective CS in a healthy woman in
uncomplicated pregnancy is now widely recognized as
being no greater than that of vaginal birth74 , although
data are not robust and, as the RCOG state in their
maternal mortality report, ‘it is virtually impossible to
disentangle the fetal and maternal reasons for most of the
operations to make a meaningful comparison.’ CS at any
stage of labor is protective of most of the serious effects
to mother and child that occur as a result of shoulder
dystocia, instrumental delivery and vaginal delivery. The
question that must be asked is why, if this is known, do
these injuries continue to occur? Shoulder dystocia can
occur unexpectedly at the end of a normally progressing
labor, but this is more likely when it is associated with
a normal-weight baby. Could the current pressure on
obstetricians to reduce the number of CSs performed be a
contributing factor? Or is it that the heat of the labor ward
is not conducive to considered thought? Predicting fetal
macrosomia does not imply that elective CS is the method
of choice, although it should be made clear to the couple
that elective CS is the low-risk option. What is important
is that each woman and her partner should be informed
of the particular risks associated with a macrosomic fetus
and shoulder dystocia. The accuracy of ultrasound should
be part of the discussion as well as the protective effect
of CS in labor on both pelvic floor disorders and fetal
trauma. Factors that will bias the advice towards elective
CS will be a small maternal stature, and other relative
risk factors such as age over 30 and history of infertility.
Ultrasound Obstet Gynecol 2014; 43: 3–10.
8 Campbell
A woman with a height over 175 cm has a significantly
lower chance of shoulder dystocia and trial of labor might
be chosen. No pressure should be placed on the couple
and, once they have decided, there is no need to revisit the
issue unless the couple request this. It is important that
the couple feel supported in the decision they make. This
is a situation in which maternal autonomy is paramount.
Conclusion
Fetal macrosomia should be defined as a birth weight
≥ 4.5 kg. It is a high-risk condition which should be
taken just as seriously by obstetricians as intrauterine
growth restriction. Neither ACOG nor RCOG/NICE, in
their guidance, appear to be proactive in dealing with
this problem. The cost analysis by Rouse et al.9 , on
which they lean heavily, does not factor in correct data
on long-term effects of OBPI, intrapartum asphyxia and
maternal pelvic floor disruption, and it is outdated in
many of its assumptions. The cost analysis by Culligan
et al.4 is robust, although some of their assumptions can
be disputed. I believe that the long-term risk of anal
incontinence has been exaggerated, but no account has
been made for the staggering healthcare costs associated
with birth asphyxia, which is a major component of
shoulder dystocia. There is, however, sufficient flexibility
in the cost estimates based on QUALYs75 to allow
us to be confident that elective CS at 39 weeks in
primigravidae with an ultrasound EFW > 4.5 kg is cost-
effective. Awareness of the possibility of macrosomia
should begin at the first antenatal visit. Obesity is a major
risk factor and a body mass index > 30 kg/m2 should
prompt awareness of a potential problem76 . Macrosomia
is also associated with excessive maternal weight gain.
Awareness of the problem is the key to better manage-
ment and avoidance of risk. Obstetricians and midwives
must be as aware of the dangers of a large fetus as of a
small one. Ultrasound is imprecise, but it is better than
other methods in predicting fetal macrosomia. If per-
formed assiduously, over 90% of ultrasound predictions
of birth weight ≥ 4.5 kg will be over 4 kg and this will
therefore define a group at high risk for obstructed labor,
emergency CS, assisted vaginal delivery and maternal and
fetal damage. Taking fetal macrosomia seriously means
recommending routine ultrasound assessment of fetal size
(the macrosomia scan) in the third trimester. A triage
scan between 32 and 34 weeks, with a diagnostic scan at
39 weeks, has much to commend it.
When a diagnosis of fetal macrosomia is made, the
mother and her partner must be made aware of the risks
of vaginal birth and be free to choose elective CS or trial
of labor without coercion. Induction of labor is con-
traindicated as it increases the risk of shoulder dystocia.
Flagging up all cases of predicted fetal macrosomia is
vitally important, so that the attendants in the labor suite
will recommend CS if there is any delay in cervical dilata-
tion or arrest of head rotation or descent. CS should also
be the preferred option if an abnormal fetal heart tracing
develops. Protection of the pelvic floor will prevent
Copyright  2014 ISUOG. Published by John Wiley & Sons Ltd.
years of suffering from anal and stress incontinence and
prolapse. Avoidance of a difficult birth will prevent fetal
trauma and long-term handicap, especially from brachial
plexus injury and fetal asphyxia. To paraphrase the
Lancet editorial: we are not interested in targets for CS
births; we are interested in healthy mothers and babies.
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