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OBJECTIVE:: To determine perinatal complications in infants =4500?g according to delivery mode. STUDY DESIGN:: Records of 231 mothers and live cephalic infants weighing =4500?g over a 13-year period were retrospectively reviewed. Maternal and perinatal complications were compared in relation to delivery mode. RESULTS:: Vaginal delivery (NVD) was achievable in 168/189 (88.9%) of women allowed to labor, of which 36.9% were operative. The cesarean delivery (CS) rate was 27.3%. The NVD group had a lower incidence of diabetes; however, hypoglycemia and transient tachypnea were more common in the CS group. The frequency of low Apgar scores at 1 and 5?minutes was similar in both groups. A total of 13 (7.7%) major fetal injuries were documented in the NVD group (arm weakness 3, hematoma 3, clavicular fracture 2, and brachial plexus injury 5). Shoulder dystocia was documented in only 7/13 (53.8%). CONCLUSION:: Vaginal delivery is achievable in 88.9% of pregnancies with infants =4500?g allowed to labor, at the expense of a 7.7% risk of perinatal trauma.Journal of Perinatology (2003) 23, 136-141. doi:10.1038/sj.jp.7210877 [ABSTRACT FROM AUTHOR]