SMFM Fellowship Series Article

Influence of Estimated Fetal Weight on Labor

Management
Elisa T. Bushman, MD1,2 Norris Thompson, MD1,2 Meredith Gray, MD1,2 Robin Steele, MPH1,2
Sheri M. Jenkins, MD1,2 Alan T. Tita, MD1,2 Lorie M. Harper, MD, MSCI1,2

1 Center for Women’s Reproductive Health, The University of Alabama Address for correspondence Elisa T. Bushman, MD, Department of
at Birmingham, Birmingham, Alabama Obstetrics and Gynecology, The University of Alabama at
2 Department of Obstetrics and Gynecology, The University of Birmingham, 1700 6th Avenue South, Women & Infants Center Room
Alabama at Birmingham, Birmingham, Alabama 10270, Birmingham, AL 35294 (e-mail: etbushman@gmail.com).

Am J Perinatol

Abstract Objective Prior studies suggest knowledge of estimated fetal weight (EFW), particularly
by ultrasound (US), increases the risk for cesarean delivery. These same studies suggest that

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concern for macrosomia potentially alters labor management leading to increased rates of
cesarean delivery. We aimed to assess if shortened labor management, as a result of
suspected macrosomia (
4,000 g), leads to an increased rate of cesarean delivery.
Study Design This is a secondary analysis of a retrospective cohort study at a single
tertiary center in 2015 of women with singleton pregnancies
36 weeks with documented
EFW by US within 3 weeks or physical exam on admission. Women were excluded if an initial
cervical exam was
6 cm or no attempt was made to labor. In addition, patients were
excluded for the diagnosis of hypertension, diabetes, or prior cesarean delivery, as these
comorbidities influence the use of US, labor management, and cesarean delivery indepen-
dent of fetal weight. Patients were classified as EFW of
4,000 and <4,000 g. Secondary
analysis examined the impact of US within 3 weeks of admission when compared with
physical exam at the time of admission. The primary maternal outcomes were duration of
labor and cesarean delivery. Duration of labor was evaluated as total time from 4 cm to
delivery (with 4-cm dilation being a surrogate marker for active labor), length of time
allowed from 4 cm until the first documented cervical change (or delivery), and time
in second stage of labor (complete dilation to delivery). Cesarean delivery for arrest of labor
was a secondary outcome. Student’s t-test, Mann–Whitney U-test, chi-squared test, and
Fisher’s exact test were used for univariate data analysis as appropriate.
Results Of 1,506 patients included, 54 (3.5%) had EFW of
4,000 g. Women with EFW
of
4,000 g had a larger body mass index, higher fetal birth weight, were more likely to
be undergoing induction of labor, had a more advanced gestational age, and were
more likely to have had an US within 3 weeks of delivery. They were more likely to
undergo cesarean delivery (29.6 vs. 9.3%, adjusted odds ratio [AOR]: 2.7, 95%
Keywords confidence interval [CI]: 1.3–5.5) despite not having shortened labor times. When
► estimated fetal analyzing this population by method of obtaining EFW, those with EFW based on US
weight rather than external palpation were more likely to undergo cesarean delivery (13.1 vs.
► fetal 7.9%, AOR: 1.5, 95% CI: 1.01–2.12), again without having shortened labor times.
► obstetrics Conclusion EFW of
4,000 g and use of US to estimate fetal weight do not appear to
► labor curve shorten labor management despite being associated with an increased risk of cesarean
► labor management delivery.

received Copyright © by Thieme Medical DOI https://doi.org/

March 1, 2019 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0039-1695011.
accepted after revision New York, NY 10001, USA. ISSN 0735-1631.
July 9, 2019 Tel: +1(212) 584-4662.
Fetal Weight and Labor Curve Bushman et al.
The diagnosis of abnormal labor progression is naturally
subjective and influenced by patient and physician charac-
teristics.1 The accurate and unbiased diagnosis of abnormal
labor is of vital importance in preventing the primary
cesarean delivery.2 Prior studies suggest knowledge of esti-
mated fetal weight (EFW), particularly by ultrasound (US),
increases the risk for cesarean delivery regardless of EFW.
These studies have only examined the risk of cesarean
delivery but not the mechanism by which cesarean delivery
is increased. These studies hypothesize that a potential
mechanism by which cesarean delivery is increased is by
provider concern altering labor management.3,4 It is unclear
how labor management is being altered. It is also unclear if
labor management is being altered by providers due to the
knowledge of US results that subsequently increase the risk
of cesarean delivery or if the indication for US may actually be
the reason for increased risk of cesarean delivery rather than
provider management.
We aim to further evaluate the management of labor, as a
potential mechanism for increased cesarean delivery, in the
setting of concern for macrosomia by US or physical exam.
One method of evaluating labor management is by assessing
how long patients are allowed to remain unchanged before
performing a cesarean delivery for arrest of labor or failed
induction of labor.5 As 4 cm was traditionally defined as
active labor (Friedman) and American College of Obstetri-
cians and Gynecologists (ACOG) now recommends defining
active labor at 6 cm, significant variability exists in how long
patients are allowed to labor at 4 cm without cervical
change.6–9 Based on the ACOG and Society for Maternal-
Fetal Medicine (SMFM) recommendation that longer labor
time decreases the rate of cesarean delivery in the general
population, we hypothesize that women with suspected
macrosomia will have a shorter time in labor compared
with those with an EFW of <4,000 g.7,10 In addition, it is
assumed that more providers would shorten labor times due
to concern for maternal and fetal morbidities in the setting of
prolonged labor.11–13
Materials and Methods
We performed a retrospective cohort at a single tertiary care
center in the year 2015. Electronic medical records were used to
identify all women with singleton pregnancies who delivered
after 36 weeks’ gestation and had a documented EFW on
admission. Medical students, obstetrics and gynecology resi-
dents, and boarded obstetricians trained in abstraction
reviewed all charts and extracted detailed demographic, labor,
and delivery information into a secure online database. The
primary investigator of the study reviewed 3% of charts. Of the
initial population, all singleton pregnancies delivered after 36
weeks, women were excluded if there was no assessment of fetal
weight, initial cervical exam was
6 cm, no attempt was made
to labor, or there was a contraindication to labor (placenta
previa, low lying placenta, malpresentation, active genital her-
pes simplex virus infection, nonreassuring fetal status, etc.). In
addition, patients were excluded for the diagnosis of hyperten-
sion, diabetes, prior cesarean delivery, and fetal anomaly as
American Journal of Perinatology
these comorbidities can influence the use of US, labor manage-
ment, and cesarean delivery independent of EFW. Women were
ultimately included if they had no exclusion criteria, delivered
after 36 weeks’ gestation, and had documented by EFW within 3
weeks or by physical exam on admission.
Patients were classified as EFW of
4,000 and <4,000 g,
given an increased risk of labor abnormalities at an EFW of
4,000 g.14 EFW was subcategorized as EFW by US within 3
weeks or EFW by abdominal palpation on admission. To
assess whether EFW was impacting labor management, we
evaluated multiple aspects of latent and active labor includ-
ing the time allowed in labor after reaching 4 cm, time
allowed for first cervical change after reaching 4 cm, and
time allowed in second stage of labor (complete dilation to
delivery). We chose 4 cm as a cut off for evaluation, as at our
institution, all patients <4 cm get a cervical Foley. Typically,
at 4 cm, the cervical Foley falls out or is removed with gentle
traction making 4 cm a more objective time of evaluation.
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Active labor was defined as cervical dilation >6 cm; however,
no standardized timing of cervical assessment was done and
as a result, detailed analysis of time for each cervical change
was not collected. Standard labor induction at our institution
is placement of cervical Foley (14–26F) with 30 mL if cervical
exam is <4 cm. If fetal heart rate tracing is reassuring,
oxytocin is added with initiation at 4 milliunits/min with
titration by 2 to 4 milliunits/min every 30 minutes with a
maximum dose of 30 milliunits/min. Cervical Foley is left in
for up to 24 hours prior to replacement of cervical Foley or
transition to cervical ripening with prostaglandins.
Secondarily, we compared mode of delivery by EFW, defined
as cesarean or vaginal delivery, and indication for cesarean
delivery, defined as cesarean delivery for arrest of labor or other
indication. At this institution, cesarean delivery is pursued if no
cervical progression is made in the latent phase after 18 to 24
hours of oxytocin therapy with ruptured membranes or in the
active phase (>6 cm) if no cervical change is made after 4 hours
with adequate contractions or 6 hours without adequate
contraction on oxytocin therapy with ruptured membranes,
regardless of EFW.
As a secondary analysis, we evaluated the impact of an US
EFW on the risk of cesarean delivery and on labor manage-
ment. For this analysis, women with a documented US within
3 weeks of delivery were compared with women with no
documented US.
Patient characteristics were compared with Student’s t-test
and chi-squared test as appropriate. Student’s t-test, Mann–
Whitney’s U-test, chi-squared test, and Fisher’s exact test were
used for univariate data analysis as appropriate. Potentially
confounding variables of the exposure outcome association
were identified in the stratified analyses. Multivariable logistic
regression was performed to better assess the effect of the
exposure while adjusting for potentially confounding effects.
Clinically relevant covariates for initial inclusion in multivari-
able statistical models were selected using the results of the
stratified analyses, and factors were removed in a backward
stepwise fashion, based on significant changes in the exposure
adjusted odds ratio (AOR) or significant differences between
hierarchical models using the likelihood ratio test. For all tests,

p < 0.05 was used to define significance. All analyses were
performed with STATA SE, version 13 (College Station, TX).
Results
Of the 3,151 identified women, 1,241 were ineligible (466
did not attempt labor, 274 had a first cervical exam >6 cm, 60
had a final SVE 4 cm, 70 had a fetal anomaly, and 368 had no
SVE recorded or had an initial exam of <4 cm). Of the 1,931
Fig. 1 Flow diagram for cohort derivation. EFW, estimated fetal weight; US, ultrasound.
Fetal Weight and Labor Curve Bushman et al.
(61%) eligible after exclusions, 1,506 (77%) had an EFW
documented: 1,452 (96%) had an EFW of <4,000 g (573
[40%] by US; 879 [60%] by abdominal palpation) and 54
(4%) had an EFW of
4,000 g (44 [81%] by US; 10 [19%] by
abdominal palpation) (►Fig. 1).
Women with EFW of
4,000 g were older (29.9 vs. 25.9
years old), had a larger body mass index (32.1 vs. 34.9), were
more likely to be white (23 vs. 37%), and were more likely to
be undergoing induction of labor (37 vs. 59%) (►Table 1).
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American Journal of Perinatology
Fetal Weight and Labor Curve Bushman et al.

Table 1 Demographic characteristics of patients with EFW of EFW of
4,000 g were more likely to undergo cesarean
<4,000 and
4,000 g delivery for any indication (29.6 vs. 9.3%, AOR: 2.7, 95%
confidence interval [CI]: 1.3–5.5) and for arrest of labor
EFW of <4,000 g EFW of
4,000 g p-Value (18.5 vs. 4.3%, AOR: 2.5, 95% CI: 0.9–6.2) (►Table 2).
(n ¼ 1,452, 96%) (n ¼ 54, 3.5%)
When analysis of labor duration and rate of cesarean
Age 25.9  5.4 29.9  6.1 <0.01 delivery were assessed by mode of EFW assignment, 617
Race (41%) patients had EFW assigned by US within 3 weeks of
Black 820 (56.5) 18 (33.3) <0.01 delivery and 889 (59%) had EFW assigned on admission by
White 345 (23.8) 20 (37.0) external abdominal palpation. Patients with an EFW
Hispanic 248 (17.1) 15 (27.8) assigned by US were allowed nominally more time for first
cervical change (298  245 vs. 262  205, p < 0.01, AOR: 18,
Other 39 (2.7) 1 (1.9)
95% CI: 6 to 43) but despite longer times in labor were more
Nulliparity 650 (44.8) 21 (38.9) 0.39
likely to undergo cesarean delivery for any indication (13.1 vs
Prior vaginal 795 (54.8) 33 (61.1) 0.36 7.9%, AOR: 1.5, 95% CI: 1.0–2.1) (►Table 3).
delivery
Married 412 (38.4) 21 (38.9) 0.09
Government 1,112 (76.6) 36 (66.7) 0.09 Discussion
insurance
In this cohort, women with an EFW of
4,000 g by either US or

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Tobacco use 168 (11.6) 9 (16.7) 0.25 physical exam did not have shorter labor times than women
BMI (kg/m2) 32.1  7.1 34.9  6.1 <0.01 with an EFW of <4,000 g. Despite a trend toward increased
Ultrasound 573 (39.5) 44 (81.5) <0.01 labor times, patients with EFW of
4,000 g were 20% more
performed likely to undergo cesarean delivery. When this same cohort
in last 3 weeks
was evaluated by method of fetal weight assignment, women
Induction 546 (37.6) 32 (59.3) <0.01
with an US within 3 weeks were again allowed more time in
of labor
labor but remained at higher risk for cesarean delivery. These
Gestational age 39.3  1.3 40.1  1.1 <0.01
at delivery
results challenge the assumption that the increased cesarean
delivery rate, in the setting of known EFW by US or exam, is due
Birth weight 3,218  459 3,950  399 <0.01
to physician management shortening labor times. Based on
Mean intake 2.4  1.5 2.2  1.4 0.43
these results, in this cohort, suspected macrosomia by US EFW
cervical exam
did not result in shortened times allowed in labor. Cesarean
Abbreviations: BMI, body mass index; EFW, estimated fetal weight. delivery risk may be related to either the fetal weight itself or
the indication for US.
Fetuses with EFW of
4,000 g had larger birth weights, were Due to the rising rates of cesarean delivery over the past 20
later in gestational age, and more were likely to have had an years, decreasing the rate of primary cesarean delivery has
US within 3 weeks of delivery (►Table 1). been an important area of research. In 2012, Little et al
Patients with EFW of
4,000 g did not have shortened illustrated that EFW by US within 1 month of delivery was
times in labor without cervical change after reaching 4 cm associated with an increased rate of cesarean delivery of 44%.3
(6.9  6.0 vs. 6.1  5.2 hours, p ¼ 0.26) and were allowed It was suggested that the increased rate of cesarean delivery
longer times in the second stage of labor although not was secondary to provider concern possibly altering labor
significant (1.0  1.3 vs. 0.7  0.9 hours, p ¼ 0.09). Despite management; however, no labor data were available in this
unchanged labor times between the groups, patients with an study. Although we hypothesized that suspected macrosomia

Table 2 Labor outcomes in patients by EFW of >4,000 or
4,000 g

EFW of
4,000 g EFW of <4,000 g p-Value RR (95% CI) AOR (95% CI)
(n ¼ 54, 3.5%) (n ¼ 1,452, 96%)
Cesarean 16 (29.6%) 135 (9.3%) <0.01 3.2 (2.0–5.0) 2.7 (1.3–5.5)a
Cesarean for arrest 10 (18.5%) 62 (4.3%) <0.01 4.3 (2.4–8.0) 2.5 (0.9–6.2)a
Hours allowed in labor 6.9  6.0 6.1  5.2 0.26 49 (36 to 135) 35 (118 to 47)a
after reaching 4 cm
Hours allowed for first 4.7  3.6 4.6  3.7 0.77 10 (57 to 77) 3 (67 to 60)b
change after 4 cm
Hours allowed in second stage 1.0  1.3 0.7  0.9 0.09 16 (3 to 34) 6.6 (10 to 23)c

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; EFW, estimated fetal weight; RR, relative risk.
a
Adjusted for body mass index, age, nulliparity, labor induction, and actual birth weight.
b
Adjusted for body mass index, age, nulliparity, and labor induction.
c
Adjusted for body mass index, age, nulliparity, and birth weight.

American Journal of Perinatology


Table 3 Labor outcomes in patients with estimated fetal weight by US or external abdominal palpation
US within 3 weeks External abdominal
of delivery palpation
(n ¼ 617, 40%) (n ¼ 889, 59%)
Cesarean 81 (13.1%) 70 (7.9%)
Cesarean for arrest 41 (6.7%) 31 (3.5%)
Hours allowed in labor 6.3  5.6 6  4.9
after reaching 4 cm
Hours allowed for 4.9  4.1 4.4  3.4
first change after 4 cm
Time allowed in 0.8  1 0.8  1
second stage
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; RR, relative risk; US, ultrasound.
a
Adjusted for body mass index, age, nulliparity, labor induction, and actual birth weight.
b
Adjusted for body mass index, age, nulliparity, and labor induction.
c
Adjusted for body mass index, age, nulliparity, and birth weight.
would shorten labor times, all tests were two sided and
therefore could direct a change in either direction (shorter
or longer). In 2014, a joint statement by ACOG, SMFM, and
Eunice Kennedy Shriver National Institute of Child Health and
Human Development (NICHD) was published addressing labor
definitions in an effort to decrease primary cesarean delivery
for the false or premature diagnosis of arrested labor.7 Our
study was able to combine these two concepts reaffirming that
US near the time of delivery does increase the risk of cesarean
delivery, but it does not appear to be secondary to a shortened
trial of labor or physicians preceding with cesarean delivery
sooner because of concern for a suspected large for gestational
age fetus.
The main limitation of our study is that it is a single center
with a unified approach to labor management with adherence
to guidelines established for labor arrest published in the joint
statement by ACOG, SMFM, and NICHD in 2014 labor manage-
ment.7 This unified approach to labor induction, with very few
deviations from our consensus standard of care, may not be
generalizable to other care center models. Additionally, the
decision to perform cesarean delivery is often secondary to
confounding factors such as nonreassuring fetal heart tones,
which we did not account for in this study.
The main strength of our study is the detailed patient data.
With these data, we were able to access labor data, which
allowed us to examine the duration of the active and
the second stage of labor. While many other studies have
examined EFW by US and its impact on cesarean delivery,
few have been able to examine the impact on labor manage-
ment further exploring the idea that cesarean delivery is
increased in the setting of suspected macrosomia due to
provider dependent factors. Additionally, based on post hoc
power calculations, we had >80% power to detect a 2-hour
difference in the time allowed in labor and a 30-minute
difference in the time allowed in the second stage between
exposure groups.
In conclusion, an EFW of
4,000 g, regardless of method of
assignment, is associated with an increased rate of cesarean
delivery without changes in labor times. Given these find-
Fetal Weight and Labor Curve Bushman et al.
p-Value RR (95% CI) AOR (95% CI)
<0.01 1.7 (1.2–2.3) 1.5 (1.01–2.12)a
<0.01 1.9 (1.2–3.0) 1.5 (0.9 to 2.6)a
0.20 21 (11 to 53) 3.8 (27 to 35)a
<0.01 35 (10–60) 18 (6 to 43)b
0.30 3.5 (10 to 3) 1 (7 to 5)c
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ings, it does not appear that labor management is preemp-
tively shortened due to a concern for cephalopelvic
disproportion as previously suspected in this population.
Given these findings an EFW of
4,000 g by external palpa-
tion or US appears to be an independent risk factor for
cesarean delivery and can be used to guide labor manage-
ment accordingly.
Conflict of Interest
None declared.
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