Isabella Carter
Category III fetal heart rate (FHR) tracings are a rare occurrence but are predictive of adverse neonatal outcomes. They are characterised by either a sinusoidal pattern or absent baseline variability, along with recurrent late decelerations, recurrent variable decelerations, or bradycardia. Recurrent variable decelerations refer to abrupt decreases in fetal heart rate below the baseline that occur with greater than 50% of contractions. This category of FHR tracing indicates that the fetus is not getting enough oxygen and requires immediate action, typically delivery via an emergency C-section.
| Characteristics | Values |
|---|---|
| FHR Pattern | Sinusoidal pattern or absent baseline variability |
| Recurrent late decelerations | Yes |
| Recurrent variable decelerations | Yes |
| Bradycardia | Yes |
| Minimal to absent beat-to-beat variability | Yes |
| Fetal tachycardia | Elevated heart rate of 170-175 beats per minute over a 10-minute period |
| Normal Fetal Heart Rate Range | 110-160 beats per minute |
| Variable decelerations | 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 |
| Recurrent variable decelerations | Occurring with greater than 50% of contractions |
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What You'll Learn
Sinusoidal pattern
Sinusoidal Fetal Heart Rate (FHR) is a rare occurrence and is considered an ominous sign of fetal jeopardy requiring immediate intervention. It is characterised by an undulating wave that alternates with a flat or smooth baseline fetal heart rate. This pattern was first described in 1972 by Manseau et al. and Kubli et al. in severely affected, Rh-sensitized, and dying fetuses. The term "sinusoidal" was used to describe this pattern because of its sine waveform.
Subsequent studies, such as those conducted by Modanlou et al., have associated the sinusoidal pattern with fetal-to-maternal haemorrhage, resulting in severe fetal anaemia and hydrops fetalis. This pattern implies severe fetal jeopardy and impending fetal death. It is classified as a nonreassuring pattern, which requires intervention to rule out fetal acidosis. In some cases, it may even necessitate emergency intrauterine fetal resuscitation and immediate delivery.
The sinusoidal pattern is typically persistent, but an intermittent sinusoidal pattern can also occur. This intermittent pattern is considered rare, but its true rate of occurrence is unknown. When identified, it should raise concern for maternal-fetal haemorrhage, especially when accompanied by decreased fetal movement, a common symptom in cases of newborn anaemia.
The diagnosis of a true sinusoidal pattern should include a fetal biophysical profile and the absence of drugs such as narcotics. The interpretation of the sinusoidal pattern is crucial, and any therapeutic intervention should consider both the maternal and fetal conditions. For example, fetuses with intrauterine growth restriction are particularly vulnerable to hypoxemia, which can rapidly progress.
In summary, the sinusoidal pattern in fetal heart rate is an important indicator of potential fetal distress and requires prompt assessment and intervention to ensure the best possible outcome for both mother and fetus.
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Absent baseline variability
A three-tier system is used to categorise intrapartum EFM and aid clearer FHR interpretation. Category 1 FHR patterns are considered normal, with a baseline rate of 110-160 bpm, moderate variability, and no late or variable decelerations. No intervention is necessary for Category 1 patterns.
Category 2 FHR patterns are classified as 'indeterminate' and include all patterns that are not classified as Category 1 (normal) or Category 3 (abnormal). Category 2 can include tachycardia, bradycardia with retained variability, minimal or marked variability, and recurrent variable decelerations with other characteristics such as a slow return to baseline. Although Category 2 is not predictive of abnormal fetal status, it requires continued monitoring and reevaluation.
Category 3 FHR patterns are defined by either a sinusoidal pattern or absent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia. Category 3 tracings are considered abnormal as they are associated with an increased risk of fetal hypoxic acidemia. Early detection and intervention are crucial to prevent neonatal morbidity or mortality.
When absent baseline variability is observed in conjunction with other abnormalities, such as recurrent late or variable decelerations, it falls under Category 3 of the three-tier system. This category indicates an abnormal fetal heart rate pattern and is associated with an increased risk of fetal hypoxic acidemia. Early detection and intervention are crucial in such cases to prevent potential neonatal complications or even mortality. Healthcare providers will closely monitor the fetus and may recommend interventions such as oxygen administration, changing the mother's position, or, in more severe cases, emergency delivery to ensure the best possible outcome for both mother and child.
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Recurrent late decelerations
Late decelerations are concerning as they indicate problems with placental blood flow and oxygen supply to the fetus. This can lead to serious complications such as fetal hypoxia, a buildup of acid in the fetus's blood (metabolic acidosis), and fetal acidemia. If left untreated, recurrent late decelerations can cause long-term consequences, including infant brain damage, hypoxic-ischemic encephalopathy, and cerebral palsy.
To detect recurrent late decelerations, doctors use electronic fetal heart monitoring to evaluate contractions and the fetus's heart rate. These decelerations are considered recurrent if they occur in more than 50% of contractions over a 20-minute period. Once identified, prompt evaluation and treatment are crucial to prevent adverse outcomes.
The management of labour and delivery typically involves an interprofessional team, including an obstetrician, a labour and delivery nurse, and a midwife. When recurrent late decelerations are observed, prompt intrauterine resuscitative measures must be taken to correct the underlying cause. In some cases, expeditious vaginal or cesarean delivery may be necessary if resuscitative measures fail to improve the fetal heart tracings.
The presence of recurrent late decelerations requires meticulous assessment to evaluate the cause and rule out fetal acidemia. It is essential to consider the degree of variability and the presence or absence of accelerations in the fetal heart rate tracing. Nurses and physicians must document these decelerations and closely monitor the patient to ensure timely intervention.
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Variable decelerations
Fetal decelerations refer to temporary but distinct decreases in the fetal heart rate (FHR) identified during electronic fetal heart monitoring. FHR baseline usually ranges from 120-160 beats per minute (bpm), but with fetal decelerations, the heart rate typically drops by about 40bpm below the baseline. Fetal decelerations are classified into three categories: early, late, and variable decelerations. Variable decelerations are irregular, often jagged dips in the fetal heart rate that look more dramatic than late decelerations.
The diagnosis of variable decelerations is confirmed by FHR monitoring, and immediate measures are taken. Maternal repositioning, administration of intravenous fluids, and oxygen are always necessary. Additionally, if the decelerations are persistent, tocolytics or emergency delivery may be required. Doctors decide whether variable decelerations are problematic based on what else their heart rate monitors tell them and how close the baby is to being born.
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Adverse neonatal outcome
Category III fetal heart rate (FHR) tracings are a rare occurrence, but they are predictive of adverse neonatal outcomes. This means that the fetus is not getting enough oxygen, and there is an abnormal fetal acid-base status. Category III FHR patterns are characterised by either a sinusoidal pattern or absent baseline variability, along with recurrent late decelerations, recurrent variable decelerations, or bradycardia.
A variable deceleration is a sudden decrease in fetal heart rate below the baseline, resembling an upside-down mountain with a point. This decrease is greater than or equal to 15 beats per minute and lasts for at least 15 seconds, with an onset to return to baseline of less than 2 minutes. Recurrent variable decelerations occur in more than 50% of contractions, and their depth and length can be concerning. They can deprive the fetus of oxygen, leading to brain injury and organ damage.
Minimal to absent beat-to-beat variability is another feature of Category III FHR tracings. Beat-to-beat variability refers to the fluctuations in heart rate between individual beats rather than the average heart rate over 10 minutes. In a Category III tracing, this variability is minimal or absent, resulting in a relatively smooth line.
Fetal tachycardia, or an elevated heart rate of 170-175 beats per minute over a 10-minute period, can also be observed in Category III FHR tracings. However, it is important to note that an elevated heart rate alone does not qualify for this classification.
When a Category III fetal heart tracing is detected, immediate action is required, and prompt delivery via cesarean section is often necessary. This classification serves as a critical indicator for healthcare professionals to ensure the well-being of the mother and fetus.
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Frequently asked questions
NICHD Category III fetal heart rate tracing (FHR) is characterised by either a sinusoidal pattern or absent baseline variability, along with recurrent late decelerations, recurrent variable decelerations, or bradycardia. This classification is indicative of adverse neonatal outcomes.
A Category III fetal heart tracing indicates an abnormal fetal acid-base status, suggesting that the fetus is not receiving adequate oxygen. This classification requires prompt delivery, typically via an emergency C-section.
Category III fetal heart tracings exhibit minimal to absent beat-to-beat variability, with tachycardia and decelerations. The decelerations are large and deep, lasting longer than the standard duration, resulting in oxygen deprivation and potential brain injury or organ damage to the fetus.
