A maternity medical record isn’t just a single file. It’s a collection of forms and computer records made over many months, stored in various places, and often owned by several groups. If you and your family are trying to come to terms with what happened during your baby’s birth, knowing what’s in this collection of records, and how to access them, matters more than most people realise.
What actually makes up a maternity medical record
Many people imagine “the notes” to be a neat manila folder passed over at discharge. In reality, a maternity record is more like a patchwork – cobbled together from a dozen different sources over pregnancy, labour, and weeks after birth. Some of it is siloed on the NHS Trust’s hospital systems – nowadays digital platforms like BadgerNet coexisting with those labour ward paper charts. Some of it is held by the GP surgery, which keeps a copy of the referral letter, an appointment summary, and postnatal check records that never cross over into the hospital’s own files.
This split matters, because if you ever need to puzzle out exactly what occurred over a pregnancy or delivery, you can’t assume that one request will yield everything. You must know which document is kept where, which of course demands knowing about their existence in the first place.
The six elements that make up the record
The cardiotocography (CTG) trace records the baby’s heart rate alongside the mother’s contractions, first from a belt-like monitor and later by a clip on the baby’s scalp. It’s here that the clearest real-time evidence of fetal distress or otherwise is found, and where legal disputes often centre. NICE guidance says continuous monitoring (as opposed to intermittent listening with a sonicaid) should only be offered in labour if there are specific concerns, but in practice it’s usually used increasingly as labour progresses, regardless of whether indications have changed. Computerised printouts are hard to read and many midwives simply describe them as “suspicious”: a note here records any missed abnormalities in more formal review.
The operative notes will typically give quite a detailed account of what happened during a birth-related surgery. They might, for example, record an obstetrician sharing concerns about a uterus being thin or weak, or noting damage done during a previous caesarean. They can record a moment when a surgeon clearly anticipated the risk of ‘extension upwards’ and elected to manage delivery through forceps rather than traction.
The anaesthetist’s charts can also be surprisingly revealing in some cases. A failure to adjust an epidural or administer a spinal block can sometimes carry as much weight as an incorrectly placed needle.
Similarly, the mother’s clinical records will often show times drugs were given and what effects they had. It might show, for example, a mother feeling extremely drowsy after administration of a particular drug/medication or suggest it was inappropriate for her to be given it at that stage of labour. While sometimes these records can be altered, they are usually a reliable contemporaneous record of events.
Records should include all letters to and from the patient throughout their pregnancy or birth and any written referral to an expert. Any record of the mother consenting to a procedure, such as an elective caesarean or induction, must be signed and dated by the mother herself, confirming that she understood the risks and benefits and any alternatives. It should be clear that the discussion followed the guidelines of the relevant professional bodies and that the risks appropriate to the specific case were discussed.
Lastly, we have the paperwork trail: referral letters from community midwives to hospital consultants, appointment correspondence, and signed consent for something like a caesarean section or an epidural. In particular, the consent forms can be important if there is a disagreement over whether the risks were outlined prior to a procedure.
Why the CTG trace carries so much weight
Let’s talk about the CTG trace again. Maternity records are generally written after the event; the midwife records what happened in her own words, her own view, after the event, and often from memory. The CTG is different. It’s a real-time, machine-generated record that is produced at the time, a contemporaneous read-out that is not dependent on memory or interpretation.
That’s why independent expert obstetricians are prepared to take it as the “anchor” document. They can examine the trace along with the timed notes and ask a very focused question: At what time would a competent clinician have appreciated that there was a problem, and how long was it before something was done? The time between those two timestamps is often where negligence cases are won or lost.
How to actually get hold of the records
Requesting your maternity notes is a legal right, not a kindness. The UK GDPR and Data Protection Act 2018 entitle you to submit a ‘Subject Access Request’ to the NHS Trust that treated you, which they must respond to in full within one month, for no charge. This covers all your hospital-held maternity notes – not just those made by midwives but the CTG traces, partograms, operative notes, and neonatal observations.
GP-held notes are a different issue. While the GP practice holds a summary of your maternity care (copies of antenatal referrals, appointment history etc), not the trust, you will also need to send a second, separate SAR to your surgery if you want the full picture. Most families don’t appreciate this detail until they’ve already waited a month for the hospital’s response and don’t find certain documents.
A few practical things are helpful to know before you put in a request:
Records often do come in a somewhat mixed format – pages you can see are old-fashioned written notes that were scanned in, some printouts from modern computer systems, sometimes a disc, or rarely an electronic link. Don’t worry unduly that this means that some pages are ‘missing’ – that’s just the way it is with a two-tier system and differing NHS administrative storage practices. Do worry that pages aren’t legible, aren’t consecutively numbered, or sections referenced in one document aren’t attached if they are relevant to your care (for example, a scan report mentioned in the notes). This may mean submitting another request once you know what to ask for.
Some content may indeed be held back on the basis of containing information about another person. This is pretty routine and might simply apply to the signatures of hospital staff having been redacted. If whole sections are consistently blacked out you may wish to write to the Trust for clarification.
Don’t wait years to request them
There’s a legal reason to move early. Claims for birth injury generally need to be issued within three years of the injury, or – because the injured party is a child – before the child’s 18th birthday, whichever gives more time. That sounds generous, but records get harder to interpret the longer you leave it, and staff memories fade even though the written record doesn’t. Requesting the full bundle as soon as you have concerns, rather than waiting until years later, gives everyone – including any expert who later reviews the case – a cleaner evidence trail to work from. This is where a Birth Injury Lawyer has a role in the process – requesting both SARs, chasing down GP and hospital records separately, checking for gaps or missing pages, and instructing the right experts to review the bundle properly before any decision is made about pursuing a claim.
What it means if part of the record is missing
At times, a trust may not be able to produce something. A CTG trace might have been mislaid, a partogram not uploaded onto the system, or a bundle of notes lost in an internal transfer. This may occur more often than claimants might imagine, and it does not instantly render the case non-compensable. In some situations, it may even provide a tactical advantage to the family.
If a trust cannot produce a document it is expected to have in place – particularly something as fundamental as a CTG trace covering the period around delivery – a court may in appropriate circumstances infer that the missing evidence would have supported the claimant’s case rather than the defendant’s. Defendants are under a duty to keep and disclose all relevant records, and a breach of that duty does not on its own absolve them of liability.
What happens to the records once a claim starts
Once a legal case is launched, the maternity record ceases to be a private document and instead becomes part of an evidence bundle bound by court rules. In a standard disclosure obligation, as set out by the Civil Procedure Rules, both the family and the NHS Trust must disclose all documents upon which they intend to rely, whether they support their case or not.
The record is then passed to independent obstetric and midwifery experts, who study it in granular detail to offer an expert opinion on the two separate questions: was care substandard, and was that poor care the cause of the injury. These are separate questions, and a case can fail on either one even if the other, to a layperson at least, seems clear.
This stage is where the scale and complexity of the case begin to emerge. Maternity claims are 10% of NHS clinical negligence claims by number, but close to 50% by value. Reading a CTG trace properly, cross referencing it with a partogram and operative notes, and determining whether a delay in escalation caused a specific injury is specialist work. Families are not expected to be able to do it themselves, and trying to interpret raw obstetric data without guidance can lead to false hope or unnecessary despair in either direction.
The record is the starting point, not the whole story
Obtaining the full maternity record is the first tangible step most parents can take after a traumatic birth, and one you have every right to do straight away. The records themselves won’t tell you if anyone is at fault – that’s a decision for the medical experts and solicitors once they have all the information there is. But without the records, no one can even start to ask the right questions.
