Introduction : Macrosomia, defined as a birth weight exceeding 4,000 grams, is an increasing concern in obstetric practice due to its associated delivery risks. Early induction of labor for large-for-gestational-age fetuses has been proposed to reduce shoulder dystocia and birth trauma, but the impact on maternal outcomes remains controversial. Methods : This retrospective multicenter study was conducted across three French university hospitals over a five-year period (2017–2023). Included were women with singleton term deliveries (≥37 weeks) and confirmed birth weight >4,000 g. Women with more than one previous cesarean, multiple pregnancy, breech presentation, or medical indications for elective cesarean were excluded. Labor induction was performed according to local DAME-based protocols. Patients were admitted either the morning of or the day before induction. For a Bishop score <6, cervical ripening was proposed using prostaglandins, oral misoprostol, or a double-balloon catheter, with method selection based on patient preference. For a Bishop score ≥6, induction of contractions was initiated using prostaglandins. The primary outcome was mode of delivery; secondary outcomes included postpartum hemorrhage (PPH), perineal injury, and neonatal morbidity (Apgar score, cord pH, shoulder dystocia). Analyses were adjusted for maternal age, pre-pregnancy BMI, parity, diabetes, and birth weight. Results : Among 76,375 deliveries, 4,300 met inclusion criteria (1,794 inductions and 2,496 spontaneous labors). Induction was associated with higher cesarean rates (45% vs. 10%; adjusted OR 2.43 [1.42–4.17] at 38 weeks and 1.85 [1.24–2.78] at 39 weeks) and increased PPH (27% vs. 15%; adjusted OR 1.82 [1.17–2.84] and 1.51 [1.08–2.11], respectively). Multiparity was protective, while each BMI unit increased cesarean risk by 6%. No significant differences were observed in Apgar <7, shoulder dystocia, or neonatal pH. Results : were consistent in sensitivity analyses using ≥90th and ≥95th percentile thresholds. Conclusions : In confirmed macrosomia, labor induction was associated with increased cesarean delivery and postpartum hemorrhage without neonatal benefit. These findings highlight the need for cautious, individualized decision-making and improved accuracy of prenatal fetal weight estimation to reduce unnecessary inductions.
