Why Record Keeping Matters in Midwifery – And What It Means For Your Care
If you’ve ever wondered why midwives or doctors make so many notes about your appointments, scans, conversations, and decisions, you are not alone. Good record keeping is at the heart of safe, responsive maternity care. It’s not an administrative box-ticking exercise. It’s a continuous narrative of your care, the decisions that were made, and why they were made.
Your maternity records are the closest thing you have to an objective account of your pregnancy and birth. They are used by clinicians to:
assess risk and monitor changes over time
share information between professionals
guide decisions in appointments or labour
document informed consent or explanation of care
trace timelines if complications arise
For families searching for clarity after an experience that felt confusing or unresolved, maternity records can be invaluable. They help you understand not just what happened clinically, but how care was delivered and whether expected standards were met.
What exactly are midwifery records?
Maternity records are the collection of all notes, documentation, and data relating to your pregnancy, birth, and immediate postnatal care. These may include:
entries from antenatal appointments
scan and test results
information about symptoms and concerns you raised
risk assessments and care plans
details of labour, progress, timings, and decisions
postnatal checks and discharge summaries
These notes may be paper-based, electronic, or a mix depending on the hospital or Trust. Some units also use digital systems such as BadgerNet, which families can access directly.
Maternity notes are created by midwives, obstetricians, sonographers, and other clinicians involved in your care. Each entry aims to capture what was done and why, and importantly, what you were told and what you understood.
Why accurate record keeping makes a difference
It supports continuity of care
Pregnancy is a journey shared by many professionals. Your community midwife, hospital team, sonographer and GP all need a clear picture of your history. Well-kept notes ensure that everyone is working from the same information, reducing the risk of miscommunication or oversight.
It safeguards safety
Good notes help identify patterns or warning signs that may not be obvious in a single appointment. For example, consistent documentation of blood pressure, swelling or reduced foetal movement enables clinicians to spot risk earlier.
It helps explain decisions
Sometimes decisions are made in the moment, induction, monitoring changes, interventions. Records show why those decisions were made, which can be reassuring when you look back later.
It protects your rights
Your notes are a record of what happened and when. If you later decide you want clarity, a complaint, or legal advice, accurate notes are essential evidence.
The importance of high-quality record keeping is widely recognised in guidance from bodies such as the Royal College of Midwives.
Understanding what you can expect in your maternity records
If you have accessed your notes, you may have seen entries that feel brief or use abbreviations that are hard to interpret. Clinical language is written for other professionals first, but that does not mean it should be inaccurate or incomplete.
Good maternity records should include:
a clear timeline of appointments and events
accurate descriptions of symptoms you reported
documentation of clinical findings and test results
details of advice given and your understanding
notes of decisions and consent discussions
referral and escalation plans when concerns were identified
If notes appear inconsistent, sparse, or lacking important detail, this can make it hard to understand your care later.
What to do if your maternity records seem incomplete
It is not unusual for families to feel uncertain when reading their own maternity notes. Some entries may appear brief or clinical. However, there are steps you can take if you feel information is missing or unclear.
1. Request your full maternity notes
You are legally entitled to a copy of your maternity records under UK data protection law. The NHS Trust or midwifery service must provide these within one calendar month of your request. This includes antenatal, labour, delivery and postnatal documentation.
2. Read your notes with care
When you first get your records, take time to read them in sequence. Look for patterns and timelines rather than isolated entries. You might notice details that help explain decisions or care changes.
However, many people find their notes confusing, technical, or emotionally difficult to read on their own.
How independent review can help you understand your records
This is where a maternity records review can make a real difference.
Our services offer:
make sense of what is written in their notes
understand why certain decisions were made
identify gaps or areas that lack explanation
see how care compares with expected standards
decide what questions to ask next
This service is not about blame. It is about clarity and understanding, providing professional midwifery insight into documentation and clinical decisions.
For many people, reading their notes alone only raises more questions. An experienced midwife reviewing the records can help bridge that gap, explaining:
clinical terminology
why certain assessments were done
what was expected at different stages
whether symptoms were recorded and acted upon
how the sequence of care fits together
This can help you decide whether you want to seek further support, raise concerns, or simply gain peace of mind.
How does a maternity records review work?
A review is typically structured but personalised. It involves:
Step 1 - Receiving your full notes
You can request your maternity records from your NHS Trust. These are then securely shared with the reviewer.
Step 2 - Professional assessment
An experienced midwife reviews your records alongside general clinical standards and guidance.
Step 3 - Clear explanation
You receive a report written in accessible language, explaining what was documented, what it means, and where there may be gaps or important context.
Step 4 - Support with next steps
Based on your priorities, you can decide whether to use this information in a complaint, to ask further questions, or simply to understand your care more fully.
This process gives families a foundation of understanding on which to base future decisions, including whether to escalate concerns.
When your records may contain missing information
Sometimes records genuinely lack important information. This might happen when:
key symptoms were not documented
conversations are not recorded
diary entries are brief or incomplete
referrals are not clearly noted
escalation criteria are not clear
If you notice missing information, it does not necessarily mean negligence. However, it does mean that it may be harder to understand your care without professional interpretation.
An independent review can help identify where documentation is incomplete or unclear, and whether that lack of detail affects your understanding of your care.
Taking next steps with confidence
If your records are hard to understand or feel incomplete:
allow yourself time to read them carefully
make notes of entries that you do not understand
focus on timelines before interpretations
seek independent review to clarify clinical context
ask questions of your care team if you feel comfortable
consider complaint support if needed
Approaching records with support can make the difference between confusion and understanding.
Why families find clarity so valuable
Understanding your maternity records can provide:
reassurance about what happened
insight into clinical decisions
confidence in questions you may want to ask
clarity before raising concerns or making a complaint
emotional closure and sense-making
Many families say that reading their notes with professional interpretation helped them feel seen, heard, and understood in ways they had not anticipated.
A final note
Accurate and detailed record keeping is central to safe maternity care. When those notes are clear, meaningful, and complete, they support continuity, safety, communication, and decision-making.
If your notes feel confusing or incomplete, that uncertainty is understandable. Record review is not about blame. It is about making sense of your care, understanding what happened, and deciding what you want to do next, at your own pace, and without pressure.
This article is for informational purposes only and does not replace clinical, legal, or psychological advice.