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Sonographic Fetal Asymmetry Predicts Shoulder Dystocia

To the Editor: In the study by Miller et al,1 the obstetricians used the sonographically calculated estimated fetal weight (EFW) to decide whether to recommend attempting vaginal or cesarean delivery. This study was conducted by a tertiary care center with a large referral and “high-risk” patient population. Presumably, experienced sonographers performed the fetal measurements, underestimating the actual newborn weight in 55.4% of the neonates. The obstetricians adhered “to American College of Obstetricians and Gynecologists (ACOG) current recommendation regarding cesarean deliveries of extremely macrosomic fetuses born to diabetic and nondiabetic mothers.” Fetuses with EFW’s of less than 4500 g were permitted to attempt vaginal delivery. For the fetuses that were able to deliver vaginally, this adherence to the 4500-g cut point resulted in a shoulder dystocia rate of 14.3%. In their discussion, the authors stated, “Although not quantifiable, it is likely that some delivery notes were incomplete, omitting the diagnosis altogether,” implying that the rate of shoulder dystocia could have been even higher than 14.3% because of the well-recognized underdocumentation of shoulder dystocia. On the basis of a 14.3% shoulder dystocia rate, do the authors continue to use the ACOG 4500-g cut point for recommending cesarean delivery to diabetic mothers, or have they lowered it to 4250 or 4000 g? Would they recommend that centers with less ultrasound expertise than their unit use a lower cut point than 4500 g to offer cesarean delivery to diabetic mothers?