INTRODUCTION: For low risk pregnancies, cesarean deliveries have a greater risk of morbidity and mortality than vaginal deliveries. Fetal macrosomia, especially at weights greater than 4500 g, also increases risks of both neonatal and maternal morbidity. Macrosomia, with estimated fetal weight (EFW) greater than 5000 g or greater than 4500 g in women with diabetes mellitus, is the currently accepted ACOG threshold at which cesarean delivery may be offered. This study evaluates current adherence to ACOG guidelines for cesarean deliveries for macrosomia at a large academic medical center. METHODS: We analyzed cesarean deliveries performed for suspected fetal macrosomia among individuals undergoing cesarean delivery between September 2018 and August 2019. Using the recorded EFW and actual birthweights, we determined whether criteria for indicated cesarean delivery for macrosomia was met. RESULTS: During the study period, 1,716 cesarean deliveries were performed with 24 performed for presumed macrosomia. The average EFW among those 24 undergoing primary cesarean delivery was 4399g. Of the 24 deliveries, 7 pregnancies were complicated by diabetes. Only 4 (17%) met the EFW thresholds, 2 of which had pregnancies complicated by diabetes. The average difference in EFW and actual birthweights was 371g (8%). 13 of the 24 ultrasounds performed for macrosomia had EFWs larger than the actual birth weight. CONCLUSION: The majority of primary cesarean deliveries performed for macrosomia did not follow currently accepted ACOG guidelines. Quality improvement initiatives aimed to improve adherence to these guidelines may provide an opportunity to facilitate efforts to decrease primary cesarean delivery rates.