Medical Malpractice
Category III Fetal Heart Strips: Recurrent Variable Decelerations
If you are a lawyer with a birth injury case, you need to be able to read fetal heart strips like an obstetrician. The purpose of this page is to help lawyers and parents better understand how to read fetal heart monitor strips.
- Categories of Fetal Heart Tracing
- What Is a Category 1 Fetal Heart Tracing?
- What Is a Category 2 Fetal Heart Tracing?
- What Is a Category 3 Fetal Heart Tracing?
- Category 3: Minimal Variability with Recurrent Decelerations.
- Why Are Minimal Variability with Recurrent Decelerations a Warning Sign?
- Causes of Minimal Variability with Recurrent Decelerations
- What Is a Variable Deceleration and What Does It Look Like?
- What Is a “Shoulder” in a Fetal Heart Tracing?
- Doctors and Nurses Have to Stay on Top of the Baby’s Condition
Categories of Fetal Heart Tracing
Before we read the tracings, let’s first understand the general categories of strips. Fetal heart tracings into three broad categories: Category 1, Category 2, Category 3.
What Is a Category 1 Fetal Heart Tracing?
Category 1 fetal heart tracings are predictive of a normal acid-basis status for the fetus. In other words, a Category 1 fetal heart tracing means the baby is getting enough oxygen.
So a Category 1 strip means things are going well. It is not, however, the time for doctors and nurses to become casual about the risks to the mother or the fetus. It is not unusual for a mom to start with a Category 1 and end up requiring an emergency cesarean section because of a Category 3 fetal heart tracing.
As a result, it is important for nurses and physicians to pay careful attention to the fetal heart tracing and to interpret the fetal heart strip in the context of the mother and fetus’ condition.
What Is a Category 2 Fetal Heart Tracing?
A Category 2 fetal heart tracing is indeterminate and requires further evaluation, clinical correlation, and continued surveillance.
A Category 2 tracing is cause for concern and common at the same time. They are a warning sign> yet most pregnancies have at least one Category 2 tracing. There is not always an identifiable reason for a Category 2 tracing.
What is the appropriate response to a Category 2 strip? The doctors and nurses must continuously monitor fetal heart rate and contractions via the fetal monitoring strips. They must increase their monitoring and awareness of the monitoring as features of the strip give rise to concern whether oxygen is getting to the fetus.
In some cases, a Category 2 fetal heart tracing may show signs of persisting despite medical treatment or progressing to a Category 3 fetal heart tracing. In both situations, delivery, usually via an emergency C-section, may be required.
What Is a Category 3 Fetal Heart Tracing?
Meanwhile, a Category 3 fetal heart tracing is predictive of an abnormal fetal acid-base status, meaning that the fetus is not getting enough oxygen. Category 3 fetal heart tracings require immediate action and prompt delivery via cesarean section.
Category 3: Minimal Variability with Recurrent Decelerations.
There are many different types of Category 3 fetal heart tracing. This page is focused on minimal variability with recurrent variable decelerations.
Why Are Minimal Variability with Recurrent Decelerations a Warning Sign?
Minimal variability is a troubling sign. It indicates that oxygen reserves are being depleted. Similarly, repetitive and persistent late decelerations are a reliable sign of oxygen deprivation.
So from the very first time a doctor or nurse sees minimal variability with recurrent decelerations, it is a bullhorn warning that this child’s oxygen reserves will soon be completely spent.
If the doctors and nurses ignore that warning or fail to recognize that periods of minimal variability accompanied by recurrent decelerations are indicative of abnormal fetal acid-base status and hypoxia, the child runs the risk of a serious birth injury or death.
Causes of Minimal Variability with Recurrent Decelerations
Common causes of variable decelerations include head or cord compression. Head compression usually occurs while pushing during labor and delivery, while cord compression can be from a short cord, nuchal cord wrapped around the fetal neck, body enlargement, prolapsed cord, decreased amniotic fluid, or the forces of labor.
What Is a Variable Deceleration and What Does It Look Like?
A variable deceleration is an abrupt decrease in fetal heart rate below the baseline. This generally looks like an upside mountain with a point. The decrease is greater than or equal to 15 beats per minute, lasting greater than or equal to 15 seconds and less than 2 minutes from onset to return to baseline.
The onset, depth, and duration of variable decelerations commonly vary with successive uterine contractions. However, variable decelerations become “recurrent” when it is occurring with greater than 50 percent of contractions. This is an example of a Category 3 fetal heart tracing with recurrent variable decelerations.
Two things are being recorded in this heart tracing. The upper part of the tracing is the fetus’ heart rate. The lower part is the mother’s uterine contractions. A contraction occurs when you see a spike in the line, once again looking like a mountain (this time right side up).
This tracing also has recurrent variable decelerations. Although each variable deceleration is short in terms of its peak, they are occurr
ing with nearly every contraction. You can see this by matching it up with the contraction beneath it.
In addition, this fetal heart strip has minimal to absent beat-to-beat variability.
Unlike the baseline heart rate, the beat-to-beat variability is not looking at the average heart rate over 10 minutes, but how much the heart rate is going up and down between individual beats. Is it a line with a lot of ups and downs, or is it a pretty smooth line? Here, the line is relatively smooth, meaning there is minimal to absent beat to beat variability.
This feature, in addition to the tachycardia and decelerations, makes this a Category 3 fetal heart strip that requires immediate delivery via cesarean section.
The fetus in this Category 3 strip also has fetal tachycardia, or an elevated heart rate of 170 -175 beats per minute over a 10 minute period of time. A normal fetal heart rate is 110 – 160 beats per minute. An elevated heart rate by itself does not make this a Category 3 fetal heart tracing. However, the fact that it is present with the decelerations most likely indicates that the fetus’ heart is pumping faster to supply more oxygen to the rest of its’ body. Unfortunately for this patient, the fetus’ conditioned worsened over time as is seen in the below strip.
This fetal heart tracing occurred approximately 30 minutes later. This is also a Category 3 fetal heart tracing with the fetus experiencing large, deep variable decelerations. The depth and length of the decelerations are worrisome. To use an analogy, imagine being dunked underwater in a swimming pool, but not have enough time to come up for air between dunks. That is exactly what is happening here. The fetus is being deprived of oxygen with every contraction. The decelerations are lasting so long that the fetus has no opportunity to get oxygen from the mother. As result, the fetus suffers a brain injury and organ damage.
What Is a “Shoulder” in a Fetal Heart Tracing?
Another feature worth discussing here is the presence of something called a “shoulder.” If you look closely, after each variable deceleration the heart rate returns to the baseline and then continues a little higher for approximately 30 seconds or so. This represents the fetus gasping for breath following each deceleration. The fetus is overcompensating with an elevated heart rate when the contraction finally stops. Once again, this is just further evidence that action needs to be immediately taken to deliver this baby.
Doctors and Nurses Have to Stay on Top of the Baby’s Condition
Ultimately, it is the nurse’s and physician’s responsibility to read and interpret fetal heart tracings, not only by interpreting the tracing, but by considering it in the context of the patient’s condition.
In this particular case, the patient was a type 1 diabetic, who was at high risk for complications, including a lack of oxygen being transferred to the fetus during labor. Fetus’ of type 1 diabetic mothers are at high risk for developing depleted oxygen reserves. This a fancy way of saying they cannot last very long if their oxygen supply is reduced during labor and delivery.
Based upon these fetal heart tracings it was clear that this fetus was not tolerating the forces of labor and delivery and suffering injury. This is why an emergency cesarean section was required.
FAQs About Category 3 Tracings and Birth Injury Cases
What Are Category 3 Fetal Heart Rate (FHR) Tracings, and Why Are They Significant in Birth Injury Cases?
How Quickly Must a Doctor Act When Category 3 Tracings Appear?
Immediate delivery is the only appropriate response to a sustained Category 3 tracing. The 30-minute rule—which requires a C-section to be performed within 30 minutes of the decision—is widely accepted as the standard of care.
But, sometimes, faster action is necessary. Many our our experts argue that when a Category 3 tracing appears, doctors should act within minutes, not wait the full 30 minutes. Any delay in delivery increases the risk of severe brain damage or death.
Can a Hospital Defend Itself by Saying Category 3 Tracings Don’t Always Lead to Injury?
How Do Defense Attorneys Try to Justify Delays in Responding to Category 3 Tracings?
What Makes a Strong Medical Malpractice Case Involving Category 3 Tracings?
– a delay in ordering or performing a C-section despite clear signs of fetal distress
– expert testimony from obstetricians and neonatologists stating that a faster delivery could have prevented the injury
– medical records documenting fetal acidosis
– low Apgar scores
-neonatal encephalopathy
– a clear link between the delay and the baby’s permanent condition, such as cerebral palsy or developmental delays.
Fetal Monitoring Negligence – Verdicts & Settlements
Below are summaries of recent verdicts and reported settlements in birth injury cases in which the alleged malpractice included failure to properly interpret warning signs on fetal monitoring strips.
$9,750,000 Settlement (New Jersey 2024): The infant plaintiff suffered hypoxic ischemic encephalopathy and intracranial hemorrhaging resulting in neurodevelopmental disabilities, deficits, and delays and the need for around the clock care. Lawsuit alleged that the injuries were caused by the defendants’ negligent failure to properly read and interpret signs of fetal distress on the electronic fetal heart monitoring device, which should have prompter earlier intervention.
$1,228,816 Verdict (New York 2024): The plaintiff suffered a brain injury during birth with overall cognitive and developmental delays, seizure disorder. The lawsuit claimed that the brain injured was caused by prolonged loss of oxygen during labor and delivery as a result of the defendant’s negligent failure to intervene with an emergency c-section in response to category 3 fetal monitoring strips.
$11,000,000 Settlement (Illinois 2023): Plaintiff, a now six-year-old boy, was delivered at defendant downstate hospital. Prior to delivery, fetal monitor tracings allegedly showed adverse changes, but defendant obstetrician opted not to perform a Cesarean delivery but waited for the mother to deliver vaginally, causing a 30-minute delay and ongoing hypoxic-ischemic insults to the plaintiff. The plaintiff suffered hypoxic-ischemic brain damage.
$35,182,818 Verdict (New York 2023): The mother was very close to her due date when she fell on her stomach. She went to the hospital and the defendant OB/GYN placed an external fetal monitor on her. The defendant allegedly was negligent in failing to monitor and properly interpret warnings indicators on the monitoring strips. As a result, mother suffered a placental abruption that went noticed for too long before an emergency C-section could be performed. The child suffered severe brain injuries leaving him blind and with no functional movement at all.
$4,900,000 Settlement (California 2022): In this case, the doctors and hospital staff were allegedly negligent in failing to properly interpret abnormal sinusoidal/sawtooth patterns on the fetal monitoring strips, which should have precluded the use of Pitocin. Instead, Pitocin was delivered and the mother over-responded to the drug, triggering massive fetomaternal hemorrhage. The child suffered an HIE brain injury rendering him permanently disabled.
$500,000 Settlement (Kentucky 2022): Lawsuit alleged that the fetal monitoring strips in this case showed signs of fetal distress for several hours, but the defendants failed to take any action. The child died shortly after birth due to complications resulting from HIE caused by loss of oxygen during delivery.
Contact Us About Your Birth Injury Malpractice Case
Category 3 fetal heart rate tracings are some of the most compelling evidence in birth injury malpractice lawsuits. They demand immediate action, and when hospitals or doctors fail to act, the consequences can be devastating.
If you child suffered suffered a birth injury because the doctors ignored warnings signs on the fetal monitoring strips, you may be able to file a birth injury lawsuit and get financial compensation. Contact our birth injury lawyers today at 800-553-8082 or contact us online for a free consultation.