Fetal Macrosomia 1

Fetal Macrosomia
Excessive birth weight is associated with an increased risk of maternal and neonatal injury. Macrosomia is defined as
a fetus with an estimated weight of more than 4,500 grams, regardless of gestational age.
I. Diagnosis of macrosomia
A.

Clinical estimates of fetal weight based on Leopold's maneuvers or fundal height measurements are often
inaccurate.

B.

Diagnosis of macrosomia requires ultrasound evaluation; however, estimation of fetal weight based on
ultrasound is associated with a large margin of error.

C. Maternal weight, height, previous obstetric history, fundal height, and the presence of gestational diabetes should
be evaluated.
II.

Factors influencing fetal weight

A.

Gestational age. Post-term pregnancy is a risk factor for macrosomia. At 42 weeks and beyond, 2.5% of fetuses
weigh more than 4,500 g. Ten to twenty percent of macrosomic infants are post-term fetuses.

B.

Maternal weight. Heavy women have a greater risk of giving birth to excessively large infants. Fifteen to 35%
of women who deliver macrosomic fetuses weigh 90 kg or more.

C. Multiparity. Macrosomic infants are 2-3 times more likely to be born to parous women.
D. Macrosomia in a prior infant. The risk of delivering an infant weighing more than 4,500 g is increased if a prior
infant weighed more than 4,000 g.
E.

Maternal diabetes
1.

Maternal diabetes increases the risk of fetal macrosomia and shoulder dystocia.

2.

Cesarean delivery is indicated when the estimated fetal weight exceeds 4,500 g.

III. Morbidity and mortality

A.

Abnormalities of labor. Macrosomic fetuses have a higher incidence of labor abnormalities and instrumental
deliveries.

B.

Maternal morbidity. Macrosomic fetuses have a two- to threefold increased rate of cesarean delivery.

C. Birth injury
1.

The incidence of birth injuries occurring during delivery of a macrosomic infant is much greater with vaginal
than with cesarean birth. The most common injury is brachial plexus palsy, often caused by shoulder dystocia.

2.

The incidence of shoulder dystocia in infants weighing more than 4,500 g is 8-20%. Macrosomic infants also
may sustain fractures of the clavicle or humerus.

IV. Management of delivery

A.

If the estimated fetal weight is greater than 4500 gm in the nondiabetic or greater than 4000 gm in the diabetic
patient, delivery by cesarean section is indicated.

B.

Management of shoulder dystocia

1.

If a shoulder dystocia occurs, an assistant should provide suprapubic pressure to dislodge the impacted
anterior fetal shoulder from the symphysis. McRobert maneuver (extreme hip flexion) should be done
simultaneously.

2.

If the shoulder remains impacted anteriorly, an ample episiotomy should be cut and the posterior arm

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2 Fetal Macrosomia
delivered.
3.

In almost all instances, one or both of these procedures will result in successful delivery. The Zavanelli
maneuver consists of replacement of the fetal lead into the vaginal canal and delivery by emergency cesarean
section.

4.

Fundal pressure is not recommended because it often results in further impaction of the shoulder against the
symphysis.

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