Objective: Treatment of fetal macrosomia presents challenges to practitioners because a potential outcome of shoulder dystocia with permanent brachial plexus injury is costly both to families and to society. Practitioner options include labor induction, elective cesarean delivery, or expectant treatment. We performed a cost-effective analysis to evaluate the treatment strategies that were preferred to prevent the most permanent brachial plexus injuries with the least amount of dollars spent.
Study design: Using decision analysis techniques, we compared 3 strategies for an infant with an estimated fetal weight of 4500 g: labor induction, elective cesarean delivery, and expectant treatment. The following baseline assumptions were made: Probability of shoulder dystocia in vaginal delivery, .145; labor induction, .03; cesarean delivery, .001; probability of plexus injury, .18; probability of permanent injury, .067; probability of cesarean delivery with induction, .35; with expectant treatment, .33; cost of vaginal delivery, dollar 3376; cost of elective cesarean delivery, dollar 5200; cost of cesarean delivery with labor, dollar 6500; lifetime cost of brachial plexus injury, dollar 1,000,000. Sensitivity analyses were performed.
Results: Under baseline assumptions for an infant who weighs 4500 g, expectant treatment is the preferred strategy at a cost of dollar 4014.33 per injury-free child, compared with elective cesarean delivery at a cost of dollar 5212.06 and an induction cost of dollar 5165.08. Sensitivity analyses revealed that, if the incidence of shoulder dystocia and permanent injury remained <10%, expectant treatment is the preferred method.
Conclusion: Fetal macrosomia with possible permanent plexus injuries is a concern. Our analysis would suggest that expectant treatment is the most cost-effective approach to this problem.