Many women who have had a difficult or traumatic birth retrieve their birth notes to help 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, we often support women in the process of retrieving and reviewing their birth records, and using the information to move further along the path in their healing journey.
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?
The following steps can help you get access to your birth 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 allay their fears of litigation somewhat.
- Keep in mind that you have the legal right to access your records, but you do not own them. Your request for access to your records can be denied in certain circumstances. The healthcare provider can also determine what parts, and in what format, they will allow you to access them. So, during the retrieval process it is important to present yourself as being reasonable and calm, enabling the person you are interacting with to feel empathy for your situation to increase the likelihood of getting the best outcome for your request.
- Be aware that in many hospitals an administrative fee is applied. It is not uncommon for some private hospitals to charge a large fee and to suggest that for you to avoid this cost and to speed up the process, you request to have your notes sent to your family doctor. However, we have found that once this occurs, your records are considered the doctor’s property and generally remain at their office. You may only be able to discuss it briefly with the doctor, rather than explore them privately, or with the health carer of your choice. If this option is suggested, you may prefer instead to 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?
When asking for your notes, you will need to request certain information, otherwise a brief outline may be all that is offered. To gain as much information as possible, ask for your full notes including:
- Progress notes
- Partogram (labour record)
- Theatre notes and anaesthetic record if you went to theatre
- Medication chart, which may be helpful if you received significant medication, or if the circumstances surrounding the administration of the medication or the effects of the medication is relevant to your experience
- Antenatal notes if there were any problems in your pregnancy or if they induced you for some reason
- Baby Notes if there were any concerns about your baby like a special care nursery or neonatal intensive care unit 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. See Appendix A for suggestions on where to find independent midwives who may be able to help you with this.
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 (yours or someone you care about). You might gain insights about the reasons things occurred. For example, you might learn why things might have been happening a particular way in your body. Or, you might discover what was happening around you, and realise some of these things might have been happening purely for institutional reasons. You may also discover options for future birthing: perhaps options you may not have been made aware of previously and, therefore, could consider if similar things occur in a future birth.
The greatest ‘a-ha moment’ for me was acquiring a copy of the medical notes for myself and my baby, 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
Once you understand your notes, you may have all this 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. See Writing your birth story – a healing step (p445). Or, if you have already written your birth story, the process of adding this new information from the birth notes can be another cathartic tool. It can enable you to really grasp exactly what happened, and feel very certain about aspects of the birth that may have had question marks over them. Some women find that this process of writing their birth story, especially with information from their birth notes 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 Deb 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 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). Olivia
Birth notes can provide highly valuable information for planning and preparing for another birth, supporting you as you 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. It may, however, allow you to pinpoint areas that you need to grieve and process to truly heal. One woman found just seeing her signature consenting to a caesarean was 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 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, and may lead to feelings of betrayal, hurt and self-doubt, with the woman wondering, “Did it really happen or did I imagine it?”
With that in mind, 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, for example, the health carer being rushed with too many patients, through to pure negligence or falsifying records. Perhaps the health carer 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 initially do nothing that involves the health carer or you may create a situation where you feel powerless and reliant on a particular response before you can move forward in your healing.
In the first instance, it is more powerful and helpful 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’s memory or with help from 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.
To deal with the emotions that arise, we suggest reading the sections Dealing with anger (p161) and I’m so angry with my health carers (p163).
Rectifying the situation
If the events of the birth that are missing from the records are more subjective and reliant on a health carer’s memory, it will most likely be a disappointing process to try to get the records adjusted, because most of the carer’s memory of a birth will actually come from reading the notes. It can feel very disheartening and you may feel a lack of acknowledgement when they can’t recall your birth among the many they see. This situation 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 outside of your birth records, for example, a blood transfusion, an admission to intensive care, signing for drugs, or even physical evidence on you or your baby, you may be able to use this information as evidence to get the notes changed. Proceeding with this is your own decision and may depend on 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 records of you and 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
If you feel ready, we encourage you to consider taking the step of retrieving your notes. The process of exploring your notes can offer guidance in where you need to focus your healing, and help you work towards making peace and moving on from a traumatic birth.
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 for most of her time in the neonatal intensive care unit. Why? I needed to know more about Grace’s birth and to 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 happened, I needed to read through it all again and try to make sense of the jumble in my head. It wasn’t easy reading my or Grace’s notes. To this day, reading them still makes me sad and on some days, very teary. But at the same time it has been incredibly healing to read through them and when Grace is older, I’ll be glad that she can look at her notes and know what happened to her and what was done from a medical point of view. Kathryn
Some useful links:
Can I access my records from a private hospital or practitioner in Australia?
How can I get a copy of my medical records? Who owns them, what does it cost, can I challenge a refusal to grant access in Australia?
How long will my records be kept?
If the records are about your child, then they must be kept for a number of years after the child ‘comes of age’. This is different across the world. Further information may be available at the below links:
AUSTRALIA: Australian Government Department of Health. State/territory general medical record retention requirements
USA: The American Health Information Management Association
UK: NHS Choices
What is the rule for health privacy and freedom of information?
The rules for health privacy and freedom of information can differ from state to state in Australia. For example in New South Wales, “Many hospitals and even some private doctors keep copies of their records much longer than seven years. The rule for health privacy and freedom of information is that if the health care provider has a record, you are entitled to access a copy of that record if it is about you. The exception is that you have no right of access under the Privacy Act 1988 (Cth) to health records made before 2001.”1
1. Mental Health Coordinating Council, Mental Health Rights Manual, Part 3 Section H: Access to health records http://mhrm.mhcc.org.au/chapter‑3/3h.aspx. Accessed July 2015
What if I am being refused access or find my records are incorrect?
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, such as a general practitioner, specialist or private hospital, contact the Office of the Australian Information Commissioner. 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.
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