Introduction gestational diabetes mellitus is an emerging global public health threat due to adverse health outcomes. This study aimed to determine the risk factors for caesarean delivery and macrosomia among women with gestational diabetes in Nyeri County, Kenya. Methods this study used a cross-section design. Randomly, 152 women with gestational diabetes and attending antenatal clinics and maternity were enrolled in this study. Data was collected using a questionnaire upon consent. Data were subjected to binary logistic regression and binomial multiple logistic regression. Results the mean age of the women with gestational diabetes was 30.86 (SD 5.81) years. Among women with gestational diabetes, a proportion of 59.9% (n=91) delivered through caesarean delivery. The positive history of diabetes in a family, previous positive history of gestational diabetes and positive previous adverse obstetric history increased chances of caesarean section delivery by more than 3.824 (95% CI = 1.001-14.608, p=0.05), 10.331 (95% CI = 2.464-43.308, p=0.001) and 7.051 (95% CI = 1.577-31.801, 0.01) folds, respectively. Fetal macrosomia incidence was 42.1% (n=64) among women with gestational diabetes. The primary level of education, previous positive history of gestational diabetes and previous positive adverse obstetric history increased the likelihood of fetal macrosomia by more than 6.289 (95% CI = 1.241-31.870, p=0.03), 5.390 (95% CI = 1.498-19.386, p=0.01) and (95% CI = 5.804 1.349-18.423, p=0.02) folds, respectively. Conclusion antenatal health care programs and delivery facilities should be strengthened in women with gestational diabetes to improve the risk associated with caesarean delivery and fetal macrosomia.