How to Get and Read Your Birth Records After a Traumatic Birth

Somewhere in the hospital’s files is a record of everything that happened during your labour and birth: what staff saw, what they wrote down, and when. For many women, getting those records is the first step to understanding a birth they can only remember in pieces. This guide explains how to ask for them, what to ask for, and how to make sense of what you find.

Why get your birth records?

Women ask for their records for lots of reasons:

• to fill in the gaps in what they remember
• to understand why decisions were made
• to prepare for a birth debrief
• to get dates and details right in a complaint
• to plan care for a future pregnancy
• to find out whether something went wrong

You don’t have to read them straight away, or at all. Some women request their records and put them in a drawer until they feel ready. That’s completely okay.

Your right to your records

• Your own records. You have a legal right to ask for access to your health records, with only limited exceptions. Public hospitals are covered by the laws of your state or territory. Private hospitals and private practitioners are covered by the national Privacy Act.
• Your baby’s records. Your baby has their own separate records, including any time in special care or NICU. As their parent, you can usually ask for these too.
• Timeframes. Private providers are expected to respond within a reasonable time, which the Australian privacy regulator generally considers to be 30 days. Public hospitals have similar timeframes under state laws.
• Cost. Hospitals can charge a fee for copies, but it shouldn’t be excessive. Ask about the cost when you apply.
• Your partner. Your records are yours. If your partner is requesting them for you, the hospital will usually need your written consent.

Step by step: how to get your records

1. Decide whose records you need

   After a birth there are usually at least two sets of records: yours and your baby’s. If your baby went to special care or NICU, or was transferred to another hospital, there may be more. You may also have records with your GP, private obstetrician or midwife, and pathology or ultrasound providers.

2. Find the right office

   Search for the hospital’s name plus “access to medical records” or “release of health information”. Public hospitals usually have a health information service or medical records department, often with an application form. Private hospitals usually have a privacy officer. If you can’t find it, call the switchboard and ask.

3. Ask for the complete record, and name what matters

   If you just ask for “my records”, you may get only a discharge summary. Ask for your complete records for the admission, and list the parts that matter most. These usually include:

   • your antenatal (pregnancy) records, including your hand-held pregnancy record if the hospital holds a copy
   • all midwifery and medical notes from labour, birth and your postnatal stay
   • the partogram (the labour progress chart)
   • the full CTG traces (fetal heart rate monitoring), in colour, as printed traces or electronic files
   • observation charts, medication charts and fluid charts
   • anaesthetic records and operation reports (for example, for a caesarean, forceps or vacuum birth, or a perineal repair)
   • pathology and blood results, including cord blood gases
   • consent forms
   • transfer and discharge documents
   • for your baby: the birth and resuscitation record, Apgar scores, and all special care or NICU records

   CTG traces are sometimes stored in a separate electronic system and left out of a standard copy. Asking for them by name makes a real difference.

4. Make your request in writing

   Use the hospital’s form if it has one, or the template below. Include your full name, date of birth, address and the dates of your admission, and attach proof of identity if asked. Ask for an electronic copy (PDF) if that’s easier to share with your GP or a lawyer later.

5. Follow up

   Keep a note of when you sent your request. If you haven’t heard anything within a few weeks, call or email to check. When the records arrive, check them against your list. If something is missing, especially the CTG, write back and ask for it specifically.

6. If your request is refused or delayed

   The hospital should give you reasons in writing if it refuses access to some or all of your records. If you’re unhappy:

   • ask the hospital to review its decision, or raise it with the Patient Liaison Officer
   • for private hospitals and practitioners, you can complain to the Office of the Australian Information Commissioner
   • for public hospitals, you can contact the information or privacy commissioner in your state or territory

7. Plan how you’ll read them

   Before you open them, think about who you’d like with you, and when. Reading about your birth in clinical language can be confronting. Some women find it brings up a lot. There are tips on reading them safely below.

Template: request for birth records

To: [Health Information Service / Medical Records Department / Privacy Officer]
[Hospital name]
[Address or email]

Date: [date]

Request for access to health records

Patient: [Your full name]
Date of birth: [DD/MM/YYYY]
Address: [Your address]
Phone / email: [Your phone] | [Your email]
MRN: [hospital record number, if known]
Admission: [date] to [date] – labour, birth and postnatal care

Baby: [Baby’s full name], born [date of birth], MRN [if known]

I request a copy of my complete medical records for the admission above[, and the complete medical records of my baby, [baby’s name], for whom I am a parent].

Please include, in particular:
- all antenatal records held by the hospital
- all midwifery and medical notes, including progress notes
- the partogram
- the complete CTG (fetal heart rate monitoring) traces, in colour, as printed traces or electronic files
- observation, medication and fluid balance charts
- anaesthetic records and operation reports, including any perineal repair
- pathology results, including cord blood gases
- consent forms
- transfer and discharge documents
- for my baby: the birth and resuscitation record, Apgar scores, and all special care / NICU records

I would prefer to receive the records [electronically, as PDF files, by email to [email] / as paper copies by post to the address above].

Please let me know if there is a fee, and if you need anything further from me, such as proof of identity.

Thank you.

[Your name]
[Signature, if posting]

What’s in your birth records

Common terms and abbreviations

Reading your records: tips

• Start with the birth summary for an overview, then read the progress notes in time order.
• Make your own timeline as you go. Write down each time and what the notes say, next to what you remember.
• Look at the times carefully. The times on CTG traces, machines and handwritten notes don’t always match exactly.
• Watch for notes written later. Notes marked “written in retrospect” or “late entry” were written after the event, which is common in emergencies.
• Notice gaps. Long periods with no notes, or missing pages, are worth asking about.
• Don’t try to interpret the CTG on your own. Reading a CTG properly takes clinical training. If you’re worried about what it shows, ask at a debrief, or ask a lawyer to have it reviewed by an expert.
• Write down your questions for your debrief, your GP or a lawyer.

Reading them safely

It can be very distressing to read clinical notes about the most frightening moments of your life, or to see your experience described in a way that doesn’t match what you remember. Before you start:

• choose a time when you won’t be interrupted, and not just before bed
• have someone with you, or someone you can call afterwards
• read a little at a time, and stop if you need to
• consider reading them for the first time with your GP, a psychologist, a midwife at a debrief, or a lawyer

If reading them brings up a lot, PANDA’s free helpline is there for you on 1300 726 306. See Finding support after birth trauma for other services.

If something in your records is wrong

If you believe something in your records is inaccurate or incomplete, you can ask the hospital to correct it. If the hospital doesn’t agree to change the record, you can usually ask for a statement of your view to be attached. Do this in writing, and keep a copy. If you’re thinking about a claim, get advice before asking for changes, so your request is worded carefully.

What you won’t usually get

Incident reports, clinical review reports and internal investigation documents are usually kept separately from your medical record, and are often not released. If a review found problems with your care, the hospital may tell you about it in an open disclosure meeting, or in a response to a complaint.

Your records and a legal claim

If you’re thinking about a claim, you don’t need to get your records yourself first. A lawyer can request them for you, and will know to ask for everything, including full CTG traces and electronic records. Your records are then usually reviewed by independent medical experts, who can say whether your care was reasonable.

Remember that the time limit for a claim keeps running while you wait for records. In most states and territories it’s generally three years for an adult, from when you knew or should have known about the injury and its cause. Different rules apply to children.

Our free medical negligence case review includes collecting your records and building a timeline of your care, with no commitment to go further.

Frequently asked questions

This article is general information about accessing medical records in Australia. It isn’t medical or legal advice about your situation. Access rules, fees and timeframes vary between states, territories and hospitals. Legal services are provided by Peter Evans & Associates.