Different records answer different questions. Antenatal notes show risk and planning. Labour charts and CTGs show progress and monitoring. Medication and operative records show interventions. Neonatal tests show the baby's condition. Follow-up records show how any injury developed.
Antenatal notes
Antenatal records include booking assessments, visit notes, blood pressure readings, test results, ultrasound reports and referral letters. They show what risks were known before labour and how they were planned for. They also show what the mother was told. Shared-care cards and GP records may hold information missing from the hospital file.
Labour chart and CTG
The partogram or labour chart tracks observations such as contractions, cervical progress and maternal vital signs over time. The CTG records the fetal heart rate and contractions continuously, while intermittent auscultation entries record heart rate checks. Midwifery notes add context about decisions and concerns. Together these documents help establish what clinicians could see, and when.
Fetal surveillance guidance has been revised over time. Reviewers interpret these records against the standard applicable on the date of birth.
Medication and operative records
Medication charts show drugs given in labour and their timing. Operative notes, anaesthetic records and instrumental birth documentation describe interventions such as caesarean section, forceps or vacuum. Theatre records often include precise times that help reconstruct urgent events. Consent forms belong here as well.
Neonatal tests
Newborn records may include Apgar scores, cord blood gas results, resuscitation records, neonatal unit observations, blood tests and brain imaging. They describe the baby's condition at and after birth. They require specialist interpretation because results can reflect different causes and timing.
Follow-up records
Later records, such as paediatric reviews, developmental assessments, therapy reports and specialist diagnoses, show how a condition has been identified and how it is progressing. They are often central to assessing the injury and future needs. They may also inform causation, for example where imaging or genetic testing is used to explore other possible explanations.
For your next conversation
- Antenatal card, visit notes and all scan reports
- Partogram, midwifery notes and complete CTG
- Medication chart, consent forms and operative or anaesthetic records
- Apgar scores, cord gas results and resuscitation record
- Neonatal unit notes and any brain imaging reports
- Paediatric, developmental and therapy reports since discharge
Common questions
Why does the GP's antenatal file matter if the birth happened in hospital?
The GP may have recorded results, symptoms or referrals not fully reflected in hospital notes. Reviewers need the whole antenatal picture to understand what was known and when it was communicated, especially in shared care.
Are later therapy reports relevant to how the birth was managed?
They mainly help show the nature and impact of the injury and future needs, which relate to loss. Some specialist reports, such as imaging or genetic findings, may also inform causation. That is why reviewers often request them.
Sources & further reading
- OAIC: access health information (opens in a new tab)
- RANZCOG: fetal surveillance guideline (opens in a new tab)
These references support the topic’s starting points. They do not determine the facts, standard of care or law applicable to an individual matter.