Elective induction versus expectant management for suspected large-for-gestational-age fetuses: a systematic review and meta-analysis

BACKGROUND: Suspected large-for-gestational-age (LGA) fetuses present a clinical dilemma: early induction may reduce birth trauma but raise intervention risks. Previous reviews lacked recent data. OBJECTIVES: To assess whether elective induction at 37–39 weeks reduces adverse maternal and neonatal outcomes compared with expectant management in pregnancies with suspected LGA fetuses. METHODS: We systematically searched PubMed, Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov through May 2025, with no language restrictions. We included randomised controlled trials (RCTs) comparing elective induction (37–39 weeks) with expectant management in singleton pregnancies with suspected (LGA) fetuses. Two reviewers independently screened studies, extracted data, and assessed the risk of bias using RoB 2.0. Outcomes were pooled using fixed- or random-effects meta-analysis, and the certainty of evidence was evaluated using the GRADE framework. MAIN RESULTS: Three RCTs (n = 3,984) met the inclusion criteria. Induction significantly reduced shoulder dystocia (RR 0.65, 95% CI 0.46–0.91), caesarean birth (RR 0.87, 95% CI 0.79–0.95), and increased spontaneous vaginal birth (RR 1.12, 95% CI 1.06–1.19). No differences were seen in instrumental delivery, severe perineal trauma, or perinatal death. Induction lowered mean birthweight (–177 g, 95% CI − 279 to − 76) but was associated with increased neonatal phototherapy (RR 1.63, 95% CI 1.19–2.23). Certainty of evidence was moderate for most primary outcomes. CONCLUSIONS: For suspected LGA fetuses, induction around 38 weeks reduces birth trauma and caesarean risk without increasing major maternal or neonatal morbidity. Clinical discussions should weigh these benefits against patient preferences and contextual factors.