Acta Obstetricia et Gynecologica.

2008; 87: 134
145

ACTA REVIEW

The macrosomic fetus: a challenge in current obstetrics

TORE HENRIKSEN

Department of Obstetrics and Gynecology, Rikshospitalet, University of Oslo, N-0027 Oslo, Norway

Abstract
Background. There has been a rise in the prevalence of large newborns over a few decades in many parts of the world. There
is ample evidence that fetal macrosomia is associated with increased risk of complications both for the mother and the
newborn. In current obstetrics, the macrosomic fetus represents a frequent clinical challenge. Evidence is emerging that
being born macrosomic is also associated with future health risks. Objective. To provide a review of causes and risks,
prevention, prediction and clinical management of suspected large fetus/fetal macrosomia, primarily aimed at clinical
obstetricians. Methods. Medline and EMBASE were searched between 1980 and 2007 by combining either ‘fetal
macrosomia’ or ‘large for gestational age’ with other relevant terms. The Cochrane Database of Systematic Reviews was
searched for the term ‘fetal macrosomia’. Results and conclusions. Although the causes of high birthweight include both
genetic and environmental factors, the rapid increase in the prevalence of large newborns has environmental causes. The
evidence is extensive that maternal overweight and associated metabolic changes, including type 2 and gestational diabetes,
play a central role. There is a paucity of studies of the effect of intervention before and/or during pregnancy on the risk of
having an ‘overweight newborn’. It appears rational, however, that preventive measures should primarily be implemented
before pregnancy and should include guidance about nutrition and physical activity in order to reduce the prevalence of
overweight. In pregnancy, limited weight gain, especially in obese women, seems to reduce the risk of macrosomia, as do
good control of plasma glucose among those with diabetes. Prediction of fetal macrosomia remains an inaccurate task even
with modern ultrasound equipment. There is little evidence that routine elective delivery (induction or caesarean section)
for the mere reason of suspected macrosomia should be employed in a general population. Vaginal delivery of a macrosomic
fetus requires considered attention by an experienced obstetrician and preparedness for operative delivery, shoulder dystocia
and newborn asphyxia.

Key words: Macrosomia, body mass index, diabetes, caesarean delivery, pregnancy outcome

Background associated with long-term health risks for the new-

The clinical experience that a large fetus is asso-
ciated with obstetrical and neonatal complications is
well documented in a number of studies (1
5).
Historically, obstetrical concerns about large fetuses
have mainly concentrated around the pregnancies of
diabetic women. During the last 2
3 decades,
however, an overall 15
25% increase in the propor-
tion of women giving birth to large infants has been
found in different populations around the world
(6
10). Therefore, the obstetrical and neonatal
complications associated with delivery of big babies
have become a frequent challenge. In addition,
accumulating data indicate that being born large is
born (11
19).
The present article provides an overview of the
main aspects and challenges associated with fetal
macrosomia in current practical obstetrics.
Methods
Medline and EMBASE were searched in the English
language between 1980 and 2007. The basic refer-
ence terms were ‘fetal macrosomia’ and ‘large for
gestational age’. Each of the two was combined with
the following terms: risk, prevention, prediction,
management, labour induction, pregnancy outcome,
pregnancy complication, delivery and caesarean.

Correspondence: Tore Henriksen, Department of Obstetrics and Gynecology, Rikshospitalet, University of Oslo, N-0027 Oslo, Norway. E-mail:
tore.henriksen@rikshospitalet.no

(Received 21 May 2007; accepted 7 January 2008)

ISSN 0001-6349 print/ISSN 1600-0412 online # 2008 Taylor & Francis
DOI: 10.1080/00016340801899289

Clinical trials, observational studies, register studies
and reviews were selected. The Cochrane Database
of Systematic Reviews was searched for the term
‘fetal macrosomia’.
Terms and definitions of large sized fetuses/
newborns
The term large-for-gestational-age (LGA) has mainly
been used for fetuses or newborns with (estimated)
weight
90th percentile or above 2 SDs for gesta-
tional age (1,20
22). The Ponderal Index (PI) is an
indicator of body proportions of infants, defined as
body weight divided by the third power of length (e.g.
g/cm3). Macrosomia is a term mostly used for new-
borns with a birthweight in weight units above a
certain limit. However, there is no general agreement
what this limit should be. Birth weights above 4,000,
4,200 and 4,500 g are being used as definitions of
newborn macrosomia (20,22). At first glance,
achieving agreement on a generally accepted defini-
tion of fetal macrosomia seems a meaningful goal
(23). It is, however, becoming increasingly evident
that infants born large constitute a heterogeneous
group in terms of body composition as well as
metabolically (24
28). Most importantly, the con-
sequences of belonging to different subgroups of
large fetuses may be different with respect to short-
term obstetrical complications and long-term health
risks. For example, the risk of shoulder dystocia is not
only determined by the weight of the fetus but also by
its proportions (29). Maternal impaired glucose
tolerance seems to be a determinant of shoulder
dystocia and Erb’s palsy independent of birthweight
in LGA infants (30). Thus, in future the concept of
fetal ‘macrosomia’ may have to be supplemented
with information about fetal/newborn body propor-
tions, composition and metabolic characteristics.
Nevertheless, until this time, the vast majority of
studies are based on LGA and/or ‘macrosomia’ as
variables, and even these crude parameters predict
major clinical problems.
Prevalences of large sized newborns
The proportion of macrosomia, e.g. birthweight

4,000 g, varies in different populations by between
5 and 20% (3,4,7,10,21). The highest prevalence is
found in the Nordic countries, where the proportion
of newborns with a birthweight at or
4,000 g is
around 20% (10,31,32). Between 4 and 5% of the
babies weigh 4,500 g or more (31,32). The preva-
lence of large babies appears overall to have in-
creased worldwide, with a few exceptions, such as
the US (3,4,6
10,21,33).
Fetal macrosomia 135
Causes of large fetuses
For practical purposes, the causes of fetal macro-
somia may be divided into non-modifiable and
modifiable factors.
Non-modifiable factors
Genes would be considered as non-modifiable. The
relative contribution of genes to birthweight has
been estimated at 25
80% (34,35). The genes
insulin, insulin-like growth factor and their receptors
are candidate genes exerting influence on fetal
growth and, therefore, size and body proportions at
birth (34).
With the upcoming concepts of ‘epigenetic reg-
ulation’, it has become evident that nutritional and
other environmental factors during fetal life may
modify long-term expression of genes (36). ‘Epige-
netic regulation’ implies that environmental factors,
such as nutrients, may induce long lasting (years and
decades) changes in gene expression.
The extent to which genetic factors influence fetal
growth through the process of placentation remains
to be resolved. There is, however, evidence that
‘imprinted genes’ play a role in regulating supplies of
nutrients to the fetus (37). Imprinting of genes
means that only one of the parentally derived genes
is expressed in the feto-placental tissues. For exam-
ple, the gene encoding for insulin-like growth factor
II (IGF-II) is imprinted (only the paternal gene is
expressed). IGF-II seems to be an important deter-
minant of placental growth and the ability to transfer
nutrients (38). Another example of interaction
between nutrients and gene activity is the observa-
tion that maternal glucose metabolism may affect
placental gene expression (39,40).
Other factors that may be considered non-modifi-
able include fetal sex, parity, maternal age and
maternal height. Importantly, maternal age at first
pregnancy is increasing in many countries and seems
to contribute to higher birthweight (1,5,7,8). A
similar trend is found for maternal height, which is
also an independent determinant of high birthweight
in most studies (7
9). A previous macrosomic baby
is a strong risk factor for high birthweight, probably
reflecting both genetic and environmental factors
(20).
Modifiable determinants
From a practical point of view, modifiable factors
include mainly pre-gestational maternal anthropo-
metric characteristics (BMI, maternal body compo-
sition), gestational weight gain, maternal nutritional
136 T. Henriksen
intake, level of physical activity, smoking and meta-
bolic parameters, especially those related to maternal
glucose metabolism. (20,23,33,41
53).
Pre-gestational maternal anthropometric characteristics
Pre-gestational body mass index (BMI) has consis-
tently been found to be an independent risk factor
for delivering a macrosomic newborn (48,50,54
59).
This association seems to exist worldwide (59). The
mechanisms by which pre-gestational overweight
induces fetal macrosomia remain to be elucidated.
The effect of a high BMI seems independent of
diabetes/glucose intolerance (55). Thus, there ap-
pear to be additional metabolic factors related to
maternal overweight that influence fetal growth and
body proportions. Among these are elements of
metabolic syndrome, as discussed below (54,60,61).
Gestational weight gain
Weight gain seems to be a determinant of birth-
weight independent of pre-gestational BMI in most
studies (62
64). The combination of pre-pregnancy
overweight and excess weight gain confers a parti-
cular risk of fetal macrosomia (65,66).
Glucose metabolism
Diabetes in pregnancy (pre-gestational as well as
gestational) is associated with a significant risk of
fetal macrosomia (67). It has been questioned
whether gestational diabetes (type 2 and ‘pure’
gestational diabetes) predicts macrosomia indepen-
dent of maternal BMI. A majority of studies indicate
that this is so (55,58,68
71). However, maternal
BMI appears to exert a stronger influence on the risk
of macrosomia than the diagnosis of diabetes
(55,58,69). Due to a higher prevalence of mothers
with high maternal BMI than mothers with diabetes,
the former are a more important contributor to
macrosomia on a population basis. On the other
hand, maternal diabetes at any given birthweight is
associated with increased risk of shoulder dystocia
compared to non-diabetics, underscoring the im-
portance of diabetes at the level of the individual
(72).
Diabetes is diagnosed according to a given cut-off
blood glucose obtained at fasting and/or by a glucose
tolerance test (73). Biologically, however, glucose
(in)tolerance represents a continuum (74). Thus,
women with glucose values just below the cut-off
levels for diabetes may well have many of the
metabolic features of diabetes, and may therefore
carry an increased risk of fetal macrosomia. Ob-
servational studies support this notion (75
78).
Other metabolic factors beside plasma glucose, i.e.
elements of ‘metabolic syndrome’
Evaluating predictors of large fetus carries some
parallels to the prediction of cardiovascular disease
in adults, i.e. different combinations of interrelated
factors contribute to various extents to the final
outcome (79). The term ‘metabolic syndrome’ was
introduced many years ago in order to better predict
the risk of cardiovascular disease in adults (79).
Metabolic syndrome includes co-occurrence of (cen-
tral) obesity, hyperglycaemia, dyslipidemia (low
HDL cholesterol, high triglycerides, high non-
HDL cholesterol) and hypertension (79). There is
some evidence that dyslipidemia predicts fetal
macrosomia independent of maternal BMI and
plasma glucose (54,60,61,80).
Physical activity
The role of physical activity alone on the risk of fetal
macrosomia awaits clarification.
However, there is increasing evidence that physical
activity before and during pregnancy is beneficial for
several other pregnancy outcomes (see below).
Risks associated with a large fetus
Fetal overgrowth and/or being born large have both
short- and long-term perspectives for the fetus and
for the mother.
Short-term risks
High birthweight is associated with a 2
3 times
increased risk of intrauterine death (5,81
83). The
large fetus runs a higher risk of prolonged labour,
operative deliveries, shoulder dystocia and fetal
hypoxia, particularly if the birthweight is
4,500 g
(20,84
90). Large newborns run a 2- to 3-fold risk
of plexus injuries, hypoglycaemia and hyperbilirubi-
nemia, and of being transferred to the neonatal
intensive care unit (86,91
93). Short-term maternal
risks associated with fetal macrosomia include pro-
longed labour, perineal lacerations, uterine atonia,
abnormal hemorrhage and caesarean section (85,
94
96). The risk of perineal lacerations of Grade III
and IV is generally increased 3
6 times if the
birthweight is above, compared to below 4,500 g
(85,93). The risk is highest if shoulder dystocia
occurs and/or operative vaginal delivery is under-
taken (85). Maternal height is another strong

modifier of the risk of perineal (and infant) injury
related to macrosomia (94).
Long-term risks
Long-term risks for the large newborn seem to
include diabetes, overweight, metabolic syndrome,
asthma, persistent plexus injuries and cancer
(11,19,59,93,97
101). For several of the long-term
risks, genetic factors may contribute to a different
extent. For the mother, the long-term risks of giving
birth to a macrosomic infant include persistent
perineal defects and anal dysfunction (102).
Fetal body composition and risks
Studies of short- and long-term consequences of
fetal macrosomia are based on birthweight alone,
and not on fetal body proportions or composition.
There may be subgroups of large fetuses that do not
represent any risks either to themselves or to their
mother, whereas other groups of large babies may
carry risks that are even higher than currently
understood. Interestingly, there is some evidence
that for a given birthweight, the risks of shoulder
dystocia as well as caesarean section were higher in
the 1990s than in the 1970s (103). A 10-fold
increase in the rate of shoulder dystocia from 1979
to 2003 was found in Maryland, USA (104). This
could have reflected a higher prevalence of obese
(‘diabetic’) body proportions of newborns in more
recent years, and is supported by the notion that the
increased risk of shoulder dystocia at a given birth-
weight in case of maternal diabetes has been
attributed to altered body proportions of the fetus
(87,105).
Furthermore, there is accumulating evidence that
body composition at birth represents important
determinants of later health and disease (106).
Practical aspects of the clinical management of
fetal macrosomia
Prevention of fetal macrosomia
Population-based interventions. The best way to man-
age fetal overgrowth is to prevent it (107,108). Many
of the determinants of macrosomia are factors linked
to ‘affluent life style’, and should therefore be
modifiable. Importantly, as pointed out by Catalano,
maternal overweight and diabetes may lead to a
vicious circle over generations, where overweight and
diabetes may be reinforced from one generation to
the next (109). This notion is supported by experi-
mental evidence of transgenerational development of
Fetal macrosomia 137
diabetes (110). In the general population, a reduc-
tion in weight and a higher level of physical activity is
considered essential in preventing overweight, meta-
bolic syndrome and diabetes (111,112). However,
there are very few clinical trials specifically aimed at
obstetrical and perinatal effects of ‘life style inter-
ventions’ before and during pregnancy
(111,113,114). No interventional studies have been
found for macrosomia.
Maternal overweight at the start of pregnancy. The
clinician is often confronted with the problem of
advising an overweight woman who is already
pregnant. First, there is no consensus about the
definition of overweight in pregnant woman. How-
ever, the risk of pregnancy complications, including
macrosomia, increases when the body mass index
exceeds 25
27 kg/m2 (115). There is also evidence
that an increase in maternal weight between 2
pregnancies increases the risk of a large baby,
whereas a reduction in weight decreases the risk
(116). There are indications that adherence to the
recommendations of the Institute of Medicine, i.e.
total weight gain B16 kg, may reduce the risk of
fetal macrosomia, especially in overweight women
(65,66,117
119). Prevention of excessive weight
gain in pregnancy is achievable (120). Overweight
during pregnancy should be considered a risk
pregnancy. In cases where ‘controlled weight gain’
is planned (which may result in no weight gain and
even weight loss), follow-up with scheduled specia-
list visits is advisable. These visits should include
sonographic and other investigations of fetal growth
and wellbeing.
A number of studies indicate that physical activity
before and during pregnancy is safe and even
beneficial, such as improved glucose control and
reduced need for insulin in diabetic pregnancies
(121
125). The effect of physical activity on the
risk of macrosomia in the general pregnant popula-
tion as well as in diabetic pregnancies remains
unknown.
Nutritional advice in the context of macrosomia
should essentially follow that given to the general
population. It may be argued that intake of sucrose
and carbohydrates with a high glycemic index should
be kept low in pregnancy to avoid excessive glucose
excursions, particularly in overweight individuals
who more often have impaired glucose tolerance
(126
128). Among women with insulin-dependent
diabetes during pregnancy tight glucose control
reduces but does not eliminate the risk of fetal
macrosomia (67,129).
138 T. Henriksen
Prediction of fetal macrosomia
The majority of studies on prediction of macrosomia
are based on sonographic measurements employed
as either single parameters (such as abdominal
circumference or subcutaneous tissue thickness) or
combinations of measures to estimate fetal weight.
The different sonographic methods do not seem to
differ substantially in terms of power to predict
macrosomia (130
132). Sonographic methods have
also been compared with the clinical estimation of
fetal weight (132). Clinical and sonographic meth-
ods have similar and limited power to predict fetal
weight
4,000 g. The receiver operator curves for
both methods have areas under the curve of 0.80

0.95. Although this is larger than the 0.5 of a useless
test, both methods suffer from false positive and false
negative rates that may have clinically important
consequences (132). The mean absolute error in
estimating birthweight of macrosomic newborns is
250
500 g in most studies (132). In other words,
50
65% of the estimates are within 10% of the
birthweight (132). These errors apply similarly to
clinical and sonographic methods. The errors are
certainly not less in cases of maternal obesity. The
American College of Obstetricians and Gynaecolo-
gists (ACOG) has referred to a third method of
obtaining an estimate of fetal macrosomia, namely
the mothers own estimate of fetal size. One study
indicated that this method could predict macrosomia
with a probability similar to clinical and sonographic
methods (130). There is some evidence that serial
sonographic measurements may improve the pre-
dictive accuracy of fetal macrosomia (132). How-
ever, serial biometry is time-consuming and the cost-
effectiveness of such methods may be questioned.
Among women with diabetes in pregnancy, pre-
diction of birthweight is of particular interest be-
cause of the higher risk of shoulder dystocia at any
given birthweight (72,105). The current methods to
predict macrosomia have similar limitations and
error ranges when applied in diabetic pregnancies
as for the general population (132).
The use of magnetic resonance imaging (MRI) to
estimate fetal weight and even body composition
may in the future become an additional tool, but
then its clinical usefulness needs further documenta-
tion (133,134).
Taken together, the clinician remains in the
situation of having inaccurate tools to predict birth-
weight both in the general obstetric population and
in pregnancies where there is a particular high risk of
macrosomia, such as diabetes. Whether compu-
terised combinations of a number of risk factors
may improve prediction of macrosomia remains to
be established (135,136).
A main purpose of predicting macrosomia is to be
prepared for shoulder dystocia. Although shoulder
dystocia is clearly related to birthweight, prediction
of shoulder dystocia by birthweight has low power
(137
140).
Clinical management of suspected fetal
macrosomia at the time of delivery
There is ample evidence that risks to the fetus and
the mother generally increase when the birthweight
is 4,500 g or more, although birthweight
4,000 g
also carries a higher risk of some complications
compared to ‘normal’ birthweight (130). Thus, the
clinician will be exposed to question of how to
handle a situation where fetal macrosomia is con-
sidered likely by the means available. The three
choices of elective caesarean delivery, induction of
labour or expectant management are well known and
arguments for preferring each of them have been
forwarded (21,130).
Macrosomia and elective caesarean delivery in the
general obstetric population
Elective caesarean section prevents several of the
complications associated with fetal macrosomia,
especially brachial plexus injuries and maternal
perineal lacerations (141). The number of elective
caesarean sections required to prevent 1 case of
permanent injury may be so high that it hardly
justifies elective caesarean delivery in a general
population. Ecker and co-workers used actual birth-
weight as the basis to calculate the number of
caesarean sections needed to prevent one permanent
plexus injury. At a cut-off of ]4,000 g, 733
3,226
operations would be required in a general popula-
tion. For birthweight ]4,500 g, the numbers were
233
1,026 (142). However, at the time of clinical
decision birthweight is unknown. Rouse and co-
workers calculated the number of caesarean sections
required to prevent one permanent plexus injury
based on sonographically estimated fetal weight. At a
cut-off of ]4,000 g in a general population, the
number operations needed to prevent one perma-
nent brachial plexus injury ranged from 800 to
16,000 (143). If estimated fetal weight ]4,500 g
was considered, indication for elective caesarean
section prevention of one permanent plexus injury
would require 1,300
28,000 operations. Most
authors therefore consider elective caesarean section
not justified in a general population on the mere
indication of a fetal weight between 4,000 and

4,500 g (21,144). If the fetal weight is assumed to be
]4,500 g, the views on methods of delivery are
somewhat more diverse. Culligan and co-workers
calculated in a decision analysis that 16.6 permanent
plexus injuries may be prevented for each 100,000
deliveries if elective caesarean section was performed
at an estimated fetal weight ]4,500 g at 39 weeks’
gestation (145). In the same study, it was observed
that one anal incontinence case would be prevented
for every 539 elective caesarean section. A policy of
elective caesarean section for all primigravid women
with an estimated fetal weight ]4,500 g was sug-
gested (145). However, observational and clinical
studies support a policy of not routinely performing
elective caesarean section in this group (85,92,
146
148).
Induction of labour for macrosomia in the general
population
The idea of inducing labour in women with sus-
pected fetal macrosomia is to achieve vaginal deliv-
ery before the fetus reaches a size that would imply
increased risk of fetal and maternal injuries. There is
evidence from clinical trials that induction of labour
does not reduce caesarean section in women with
estimated fetal weights between 4,000 and 4,500 g
(149). Furthermore, several observational studies
show an increased risk of caesarean section without a
reduction in perinatal morbidity following induction
of labour on an indication of suspected fetal macro-
somia (150
155). Thus, current evidence shows no
benefit of a policy of routine induction of labour at
the mere indication of suspected fetal macrosomia
(]4,000 g) (156).
Expectant management
A policy of routine labour induction or caesarean
delivery in women merely because of suspected fetal
macrosomia in a general population does not seem
justified (21,157).
The decision to be expectant requires, however, a
thorough consideration of all other factors that may
argue for or against elective delivery, especially if the
fetal weight is ]4,500 g (158). Among these factors
are maternal height, BMI, previous obstetrical
history including previous shoulder dystocia and
(indications for) caesarean section and diabetes.
Post-term pregnancies in cases of suspected fetal
macrosomia need particular attention because pro-
longed pregnancy is associated with increased risk of
macrosomia as well as perinatal mortality and
morbidity (159). Close follow-up after 41 weeks
Fetal macrosomia 139
(estimated date of delivery plus 7 days) is therefore
advisable when macrosomia is suspected (159).
Management of fetal macrosomia in special
subpopulations
Previous caesarean section and macrosomia. The com-
bination of previous caesarean section and macro-
somia has become a common clinical problem.
Previous observations support a policy of trial of
labour in this group of women with a fetal weight
estimated above 4,000 g (160,161). Later studies
indicate that, in particular, a previous vaginal birth
predicts success in women with macrosomic fetuses
undergoing trial of labour after previous caesarean
delivery (160
163). Furthermore, the indication for
the previous caesarean delivery may affect the
success rate of induction. ‘Failure to progress’ as
an indication for previous caesarean section seems,
however, to be associated with a lower success rate
during trial of labour (162). Obesity seems to be an
independent risk factor for failed trial of labour in
women with previous caesarean delivery (164).
Again, when fetal weight
4,500 g is suspected,
the decision to induce labour or not needs to be
individualised in women with previous caesarean
delivery, especially in those without previous vaginal
delivery or failure to progress.
Diabetes in pregnancy and macrosomia. Among women
with diabetes in pregnancy, the risk of shoulder
dystocia is increased (142,165). Many obstetricians
practice routine induction of labour around term in
all women with diabetes (166). Furthermore, sus-
pected macrosomic fetuses lead many clinics to
perform elective caesarean section in women with
diabetes (165,167). There is, however, no consensus
at which estimated fetal weight elective abdominal
delivery should be performed in diabetic women.
Elective delivery has been recommended at estimated
fetal weights between 4,000 and 4,500 g (21,168).
Based on the prevalence of adverse neonatal outcome
in observational studies, elective caesarean section is
considered by many justifiable in diabetic women if
the fetal weight is believed to be ]4,500 g
(21,168,169). An indication for elective caesarean
section at an estimated weight
4,250 g has also
been suggested. The evidence for choosing a fetal
weight estimate as an indication for elective delivery
in diabetic women is, however, insufficient (166).
Previous shoulder dystocia. Women (with and without
diabetes) with previous shoulder dystocia have an
increased risk of recurrence, ranging from 1.1

16.7% (170,171). This wide range reflects, at least
140 T. Henriksen
partly, the absence of a uniform definition of
shoulder dystocia.
For the general population, there is insufficient
evidence to routinely recommend caesarean section
in women with previous shoulder dystocia, but is
considered by many clinicians in cases of permanent
plexus injury (21). A thorough review of previous
delivery records may be helpful.
In women with diabetes and previous shoulder
dystocia, the risk of recurrence is clearly increased.
Evidence-based recommendations of delivery route
for this particular group of women are not available.
Many obstetricians find it reasonable to consider
elective caesarean section at estimated weights

4000
4200 g based on the risk of recurrence of
shoulder dystocia in the general population
(170,172).
Management of suspected macrosomia during labour
Given a policy of expectant management of sus-
pected fetal macrosomia in a general population,
special attention during delivery is required. The
progress of labour, particularly the descent of the
head, should be carefully considered (173,174).
Close monitoring of the fetal heart rate is advisable
as fetal hypoxia is more likely in poorly progressing
labour. The macrosomic fetus may be more vulner-
able because its need of oxygen is above average.
More frequent use of oxytocin may further increase
the risk of fetal hypoxia due to uterine hyperactivity.
Frequent uterine contractions (
4
5/10 min) re-
duce the time for intervillous reoxygenation resulting
in insufficient placental gas exchange. Prolonged
second stage (more that 2 hours) is associated with
shoulder dystocia and asphyxia (173). The direction
of the sagittal suture, stage and attitude of the head,
besides signs of fetal stress, should be continually
revised. A common situation during labour of a
woman with a macrosomic infant is that at the time
of full dilation the bony leading part of the head
remains at level of the spines or apparently a little
below. If part of the head can be felt above the
symphysis, it may indicate a large and/or markedly
moulded head. Forceful extraction in this situation is
associated with a high risk of shoulder dystocia and
fetal hypoxia (174). A history of a previous compli-
cated birth, prolonged first stage, short maternal
stature, overweight, diabetes, polyhydramnios and
signs of malpresentation are factors arguing against
operative vaginal delivery. If instrumental vaginal
delivery is considered in these cases, extraction of the
infant should not be continued if it is felt necessary
to use more force than usually applied to low
vacuum/forceps. It is rational to pull during uterine
contraction and use the mother’s active pushing in
order to bring down the whole fetus and not only the
head and neck. Delivery of the head should be very
careful and if necessary slowed down by holding
back when the mother is pushing. This will reduce
the power (energy/time unit) exerted on the perineal
tissues, and also give the shoulders time to enter the
pelvic cavity. Competent and prepared assistants
should be in the delivery room so that shoulder
dystocia can be handled immediately and properly.
Since hypoxia and other injuries to the fetus may be
expected, a paediatrician should be present at the
time of delivery. Repair of perineal lesions, particu-
larly those involving the sphincter ani and rectum,
should be carried out by a senior obstetrician under
optimal conditions in an operation theatre.
Conclusion and future aspects
The ‘physiological prevalence’ of macrosomia is
unknown and may vary among different populations.
The current high proportion of macrosomic new-
borns (between 10 and 20%) in many countries
seems to be significantly caused by features of
‘westernised lifestyle’, especially maternal over-
weight. Physical inactivity may play a role, but
documentation is scarce. Reduction in pre-preg-
nancy weight and/or gestational weight gain seems
rational in order to reduce macrosomia. Interven-
tional studies with macrosomia as an end point are,
however, lacking. Prediction of fetal macrosomia
remains an inaccurate task. Advancements in sono-
graphic technology have not changed this situation.
There is a need for improved methods to estimate
both fetal weight and body proportions. Elective
delivery based on suspected fetal macrosomia in a
general population is not supported by current
evidence. Vaginal delivery of a macrosomic infant
requires, however, considered attention by experi-
enced obstetrical personnel.
Beyond the obstetrical concerns, being born too
large is associated with long-term health risks for the
newborn.
Acknowledgements
Esther Baumann is thanked for invaluable secretarial
help in preparing this manuscript.
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