Induction of labor for suspected fetal macrosomia: An updated meta‐analysis of randomized clinical trials and trial sequential analysis

Abstract

Abstract Background Fetal macrosomia is linked with increased risks of adverse maternal and neonatal outcomes, such as shoulder dystocia, cesarean delivery, and birth trauma. The optimal management strategy for non‐diabetic pregnancies with suspected macrosomia remains uncertain, with conflicting evidence from previous trials. Objective To evaluate the effects of labor induction on maternal and neonatal outcomes in this population. Search Strategy We searched electronic databases up to June 2025 to identify randomized clinical trials comparing induction of labor with expectant management for suspected fetal macrosomia in non‐diabetic pregnant women. Selection Criteria We included the studies that met the PICOs criteria. Women with pre‐gestational or treated gestational diabetes mellitus were excluded. Data Collection and Analysis Continuous outcomes were summarized as mean differences (MD) and dichotomous outcomes as risk ratios (RR), both with 95% confidence intervals (CI), using a random‐effects model. Analyses were performed using R version 4.3. The primary outcomes were shoulder dystocia and cesarean delivery. Main Results Four studies with 4024 women were included. Induction of labor significantly reduced the risk of shoulder dystocia, cesarean delivery, and fetal fracture with a pooled RR of 0.68 (95% CI 0.49–0.95), 0.87 (95% CI 0.79–0.95), and 0.28 (95% CI 0.09–0.95), respectively, compared with expectant management. However, induction of labor was associated with increased risk of hyperbilirubinemia and phototherapy with a pooled RR of 3.03 (95% CI 1.60–5.74) and 1.63 (95% CI 1.17–2.26), respectively. No significant differences were observed in brachial plexus injuries, intracranial hemorrhages, perinatal deaths, operative vaginal delivery, or perineal tear, between the two groups. Conclusion Induction of labor at full term (between 38 +0 and 38 +4 weeks of pregnancy) significantly reduced the risks of shoulder dystocia, fetal fractures, and cesarean delivery rates, with an increase in spontaneous vaginal delivery. These findings support reconsideration of current management guidelines and highlight the potential benefits of timely labor induction.