Background. Large for gestational age fetuses, also called macrosomic fetuses, represent a continuing challenge in obstetrics.
Methods. We review various problems with large for gestational age fetuses. We have performed a literature search, mainly through the database PubMed (includes the Medline database). The clinical problem is discussed from the primary care provider's, the patient's and the obstetrician's point of view.
Results. Macrosomomia is arbitrarily defined as having a fetal weight of above the 90th percentile, a birth weight of above 4000 g or 4500 g, or a birth weight of over +2 standard deviation of the mean birth weight by gestational age. The diagnosis of macrosomia is difficult, both by palpation and symphysis fundus measurement; even with sophisticated sonographic measures. The combination of biparietal diameter, femur length and abdominal circumference appears to be no better than abdorminal circumference alone..
Interpretation. Based on the literature, labor should not be induced in nondiabetic pregnancies. The best policy is to await spontaneous birth or to induce labor after 42 weeks completion. A great number of cesarean sections have to be performed to avoid a single case of plexus brachialis paresis resulting from a difficult shoulder delivery. Cesarean section should not be considered in nondiabetic pregnancies unless the estimated fetal weight is above 5000 g. In pregnancies complicated by diabetes mellitus there are reasons for selective induction of labor if macrosomia is suspected and for cesarean section if the calculated birth weight is above 4000 g. Each department should have a strategy to handle such a situation because the problem with the difficult shoulder delivery cannot be completely avoided. Different procedures of managing difficult shoulder delivery are described.