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OB Guideline 24: Macrosomia


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For the purposes of these Guidelines, fetal macrosomia1 implies growth beyond 4,500 grams (approximately 1–2 percent of live born infants achieve this birth weight). Risks for morbidity for mother and baby increase sharply beyond this weight compared to the general population. Clinical palpation and sonography are similar in their ability to estimate the presence of macrosomia.

Prenatal Counseling 

When macrosomia is clinically suspected, patients should be informed of the potential risks and such discussion should be documented in the prenatal record.

Maternal risks include:

  1. increased likelihood of cesarean delivery,
  2. vaginal lacerations, and
  3. postpartum hemorrhage.

Fetal risks include:

  1. shoulder dystocia,
  2. fractured clavicle, and
  3. damage to the nerves of the brachial plexus producing symptoms ranging from temporary upper extremity weakness to permanent paralysis, which is extremely rare (most infants delivered vaginally with birth weight >4,000 grams and a brachial nerve injury do not have a permanent paralysis).

Intrapartum Counseling 

The responsible intrapartum clinician should confirm that the patient understands the risks and document this in the intrapartum record.

Delivery Options 

If the estimated fetal weight is 5,000 grams or greater (4,500 grams or greater for infants of diabetic mothers), then prophylactic cesarean delivery may be considered.

Induction of labor for macrosomia is not recommended because it does not improve maternal or fetal outcomes and failed induction may result in unnecessary cesarean delivery.

Postpartum Documentation

In the event of shoulder dystocia, a dictated operative note or its electronic equivalent should be completed. This note shall include the indications and rationale for any procedure or maneuvers selected.

(See Guidelines 1 and 25 and the Sample Form for Documenting Shoulder Dystocia) ;


The clinician’s hospital risk management unit should be notified of all cases of infant upper extremity weakness or paralysis.

Institutional Responsibility

Each obstetrical institution is responsible for developing a plan for routine safety drills to prepare staff in the event of shoulder dystocia and other obstetrical emergencies.2


  1. Fetal macrosomia. ACOG Practice Bulletin 22. American College of Obstetricians and Gynecologists. November 2000. Reaffirmed 2013.
  2. Joint Commission:


 << Guideline 23             Web Guideline Home Page              Guideline 25 >>

May 1, 2014
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