Retrieving your birth records after a traumatic birth : how to get them, what to do with them, and why it can be a healing step

Many women who have had a traumatic birth retrieve their birth notes to aid in the healing process, and in preparation for a subsequent birth. Going over your notes (especially with a midwife who understands that birth matters) can be very powerful in helping you move to a new level of healing and knowledge. At Birthtalk.org, we often support women in the process of retrieving and reviewing their birth records, and in using the information they discover to move further along the path in their healing journey. (An excerpt from our book “How to Heal a Bad Birth”)

Birthtalk helped me ask the tough questions and to face the elephant in the room. I remember when it was suggested to us that getting the birth notes might help us in the healing process. I remember when we got them, and feeling like I had a live grenade in my hands (What if the birth was different to how I remembered? What if I feel it all again?). But when we had gone through them with Deb (from Birthtalk), it all made sense, and although it hurt, it helped us move on. Sharona

How do I get my notes?

Begin by contacting the Medical Records Department (or equivalent) of the hospital where your baby was born, to find out their particular process for retrieving your records.

You can try explaining to the staff that your reason for wanting access to your records is to be able to make sense of your birth emotionally. This might evoke a more helpful response from staff and somewhat allay their fears of litigation.

Be aware that in many hospitals, an administrative fee will apply.

It is not uncommon for some private hospitals to suggest that you can avoid this fee and speed up the process, by requesting to have your notes sent to your family doctor. We would advise against this as we have found that once this occurs your records are considered the doctor’s property and remain at their office. You may only be able to discuss it briefly with the doctor rather than revisit areas you need to later on, perhaps with privacy. If this option is suggested, we suggest that you thank the hospital, but let them know that you would rather go ahead with the initial request for all your records.

Most women find it is worth paying the fee, to be able to have the opportunity to move their healing process forward, and also to gain insights about their birth that could be useful if planning future births.

What should I ask for?

To ensure you receive as much information as possible, specify that you would like your Full Notes including:

Progress notes
Partogram (labour record)
Theatre notes and anaesthetic record if you went to theatre
If lots of medication – medication chart
Antenatal notes if there were any problems in your pregnancy or if they induced you for some reason
Baby Notes if any baby concerns like a special care nursery admission.

Now what do I do?

When my birth records arrived in the mail, I felt sick. I couldn’t bear to look at them at first, shoving them in a drawer. I was afraid of finding out that I’d imagined it all, that there would be nothing in there that would illustrate what a horrific experience it was. And worse, I was worried that it would show that I was somehow responsible for things going so wrong. After a few weeks, I took a deep breath, brought the notes out, and began to read. And thank goodness I did. Going over my notes with Deb beside me, interpreting and explaining, was a major turning point in my healing journey. Melissa

Going over your notes with a midwife who understands that birth matters, can be very powerful in moving a woman (and her partner) to a new level of healing and knowledge. It can also help with the interpretation of your hospital notes, which can be difficult to understand if you are not familiar with the environment of a maternity unit, or the terminology, abbreviations and shorthand used in note-taking.

For these reasons, we strongly encourage you to make contact with a trained midwife who understands birth trauma, and can support you in this aspect of your healing. (You can contact us for recommendations on where to find someone)

Going through your notes with a midwife who ’gets it‘ can lead to meaningful education to further your understanding of your birth and to empower you for possible future births (whether your own births or to support someone you care about who is birthing).

You might gain insights about the reasons things occurred: why things might have been happening a particular way in your body, or what was happening around you, that may have been occuring for institutional reasons. You may also discover options for future birthing: perhaps options you may have had, but not been made aware of, and therefore could consider if similar things occur in a following birth.

The greatest ‘a-ha moment’ for me was acquiring a copy of the medical notes for myself and Zander, and then spending time with Deb (from Birthtalk) breaking down what actually happened. It helped sort out in my mind what actually went on for the first couple of days we were in hospital. I felt emotionally drained but reassured about what actually happened. Another layer of the onion had come off! Tina

Moving on

Once you understand your notes, you may have new information available to support you in other Healing exercises. Using your birth records as a guide can be a great help when writing your birth story. And you may now have access to information that further enables you to make sense, make peace and move on in the healing journey, making this a very worthwhile process

Rewriting the birth story

Rewriting your story with this new information from the birth notes can be another cathartic tool, enabling a woman to really grasp exactly what happened, and feel very certain about aspects of the birth that may have been question marks for her earlier. Some women find that this process enables them to reclaim the birth experience as their own, which can be an important step towards healing.

Guess what I found out!

When one woman went over her birth notes from her traumatic caesarean birth, translated and explained by Debby from Birthtalk, she made an interesting discovery :

The notes said that I had dilated two centimetres more than I had remembered! My emotions moved from my initial anger that my body had been working so well yet still I was sectioned, to excitement to see that my body had not failed me quite as I had been led to believe. The courage and confidence boost this information gave me was palpable, and really paved the way for my journey towards my empowering VBAC (vaginal birth after caesarean). Jane

This can be highly valuable information for planning and preparing for another birth, supporting you as you decision-make your way towards an empowering experience.

Now I know what to grieve

Seeing the progress of a traumatic experience in black and white can be a difficult thing. But it may allow you to pinpoint areas that you need to process and grieve over to truly heal. One woman found just seeing her signature consenting to a caesarean to be an extremely emotive moment. She felt it signified “the end of my innocence”, and finally allowed herself to grieve for the trauma and pain that followed the birth. She said, “Every new aspect that I allowed myself to acknowledge and grieve led me closer to healing, and making peace with the experience.”.

A note of caution

Sadly, some women find that their notes do not at all accurately reflect their experience (beyond mild discrepancies such as the order of events, timings, and who was present). Sometimes there are large variances between what a woman or support people recall from the birth, and what the birth notes reflect. Unfortunately, this is a more common occurrence than most people expect. It can be a real blow to discover this, and lead to feelings of betrayal, hurt, and self-doubt, wondering: ‘Did it really happen or did I imagine it?’

With that in mind, below we share what you can do if you do find discrepancies in your notes.

When birth notes are inaccurate

Errors in birth records can range from minor details being left out, to blatant omissions of important events, or even statements that are untrue. Reasons for these discrepancies can range from lack of due care (health professional being rushed with too many clients) through to pure negligence or falsifying records. Perhaps the health professional was getting confused between patients, resulting in inaccuracies. Or a health carer may have written notes about your situation without having really investigated it, for example, not taking the time to see where you were ‘at’ emotionally, and therefore documenting with a standard line – ‘coping well’ – despite you knowing that this was not the case.

What can you do about this?

The first thing we recommend is to do nothing, initially, that involves the health professional. Otherwise you may create a situation where you feel powerless and reliant on a particular response before you can move forward in your healing.

It is more powerful and helpful, in the first instance, for you to be able to work on this for yourself. Try writing your story with what you know to be true, collating your information from what they have written, from your own memory, your partner or anyone else who was there. It can be difficult to refrain from doubting yourself, but we encourage you to hold on to what you know to be true.

(in our book, ‘How to Heal a Bad Birth : making sense, making peace and moving on’, we have chapters to help you deal with the emotions that arise, and also offer tips and ideas for writing your story.)

Rectifying the situation

If the events in the birth that are missing from the records are more subjective and reliant on a health carer’s memory, there is a large chance that it is going to be a disappointing process to try and get the records adjusted, as most of the memory of health professionals actually comes from reading the notes. It can feel very disheartening and like you have been hit with a huge lack of acknowledgement when they can’t recall your birth among the many they see, and this has the potential to unnecessarily delay your healing process further. It may be better to focus on what you can control, and change, which is your own response to your birth, and your healing journey.

However, if there are events that would have evidence available outside of your birth records – for example, blood transfusion, admission to intensive care, signing for drugs, or even physical evidence on yourself or your baby – you may be able to use this evidence to get the notes changed. Whether you proceed with this is your own decision, and may depend upon the level of incorrect information, and whether you see the correction of these oversights as being essential to your recovery, or as important for the future health record of you and/or your baby.

The most important aspect of this process is retaining power over your own experience and your own emotional clarity, so perhaps ‘sitting on the decision’ for a while might give you some space to work on your healing, and get to a place where there is less intensity involved in getting answers and changes made. Either way, you are working towards reclaiming your birth for yourself, and moving on.

A worthwhile exercise

About two months after Grace was born I requested a copy of all my pregnancy, birth and postnatal notes, along with a copy of Grace’s full medical file up for most of her time in NICU (the neonatal intensive care unit). Why? I needed to know more about Grace’s birth and fill in a lot of the gaps that I had around what happened and when. I had been in such a daze for those first few days that even though I had a recollection of what was happening, I needed to read through it all again and try to make sense of the jumble in my head. It wasn’t easy reading mine or Grace’s notes. To this day reading them still makes me sad and some days very teary. But at the same time it has been incredibly healing to read through them and when Grace is older, I’m glad that she can look at her notes and know what happened to her and what was done from a medical point. Kathryn

We encourage women who feel they are ready, to consider taking this step of retrieving their birth notes. The process of exploring this can offer guidance in where you need to focus your healing, and work towards making peace and moving on from a traumatic birth.

Footnote : If you are in Australia, and want to complain about accessing or correcting personal health information or medical records held by a private healthcare provider (a general practitioner, specialist or private hospital) contact the Office of the Australian Information Commissioner (www.oaic.gov.au/privacy/privacy-topics/health-for-individuals. This agency can assist with complaints about access to health information, charging for access to health information, correction of health information, and handling of personal health information.