Labour records are often the most important evidence in a birth injury claim, because they show what the clinical team knew, when they knew it and what they did about it. Complete and consistent notes can support or defeat an allegation of negligence. Missing, illegible or contradictory notes usually turn the argument into one about what the gaps mean.
The baby cannot give an account, and the parents’ memory of labour is rarely detailed. Prof. Sandip Hindocha, a Consultant Plastic Surgeon, prepares reports for solicitors across medical negligence claims, and the principle holds in every specialty: the record made at the time carries the case.
In short: a birth injury claim is built from the CTG trace, the partogram, the clinical entries and the neonatal notes, read together as a single timeline. Gaps in that timeline, and delays in obtaining it, are among the most common reasons a claim stalls.
Why Labour Records Decide Birth Injury Claims
Breach of duty is judged by what a reasonably competent clinician would have done at the time, the test traced in how Bolam developed into Montgomery. The only reliable way to see what was happening at that moment is the record made at that moment.
Records also protect against judging with the benefit of a known outcome, a risk covered in hindsight bias in clinical negligence. A clear timeline lets everyone ask what the team could see then, not what is obvious now.
The Records That Make Up a Labour File
A maternity file is much larger than the single set of notes most people picture. The main components are below.
| Record | What it shows |
|---|---|
| CTG trace | The baby’s heart rate and the mother’s contractions over time |
| Partogram | Progress of labour, observations and the plan at set intervals |
| Clinical entries | Assessments, decisions, who attended and when they were called |
| Antenatal notes | Risk factors identified before labour began |
| Neonatal records | Condition at birth, resuscitation, cooling and early tests |
| Incident and review documents | Internal investigations and any later explanation given to the family |
The CTG Trace and What It Can Show
A cardiotocograph (CTG) records the baby’s heart rate alongside the contractions. National guidance on fetal monitoring in labour is set out in NICE guideline NG229, which also covers how CTGs should be recorded and kept.
Reading the Whole Trace
Experts review the full trace, not only the sections a note refers to. The pattern over time, and the point at which it changed, is usually more informative than any single moment.
Missing or Incomplete Traces
A trace that stops, is not stored or cannot be produced is a serious problem for both sides. It removes the best objective evidence and leaves the case to rest on written entries and recollection.
The Partogram and Clinical Entries
The partogram charts progress through labour, with observations and the plan recorded at set intervals. NICE guidance expects a systematic assessment of the woman and baby to be documented regularly, and more often if there are concerns.
Clinical entries add the reasoning: who reviewed the woman, what they concluded and what they decided. Entries that are timed, signed and specific are far more persuasive than general phrases such as “CTG reassuring” with no detail behind them.
When the Notes Are Missing, Late or Inconsistent
Late entries, unsigned entries, times that do not match the CTG clock and handwriting that cannot be read all weaken a record. None of these proves negligence on its own, but each gives the other side something to question.
Where an entry is added after the event, its timing matters. The wider role of notes as evidence is explored in medical records as evidence in a negligence claim.
How Long Records Are Kept and How to Obtain Them
Maternity records are retained for a long period, because they also form part of the child’s record. The current period is set by the NHS Records Management Code of Practice, and a solicitor should check it directly rather than rely on a summary.
A solicitor will usually request the complete file, including the original CTG, rather than a typed summary. Asking early avoids later disputes about what exists.
Early Notification and Internal Reviews
NHS Resolution’s Early Notification Scheme, introduced in 2017, reviews cases where a baby born at term (at least 37 weeks) after labour shows signs of a potentially severe brain injury in the first seven days of life. Trusts in England tell NHS Resolution about qualifying cases and also report them to Maternity and Newborn Safety Investigations (MNSI), whose safety report is later shared with NHS Resolution. The aim is faster learning and, where appropriate, earlier support for families.
Internal investigation reports and incident reviews are separate from the clinical record, but they can be relevant to what happened and to what the family was told.
How Experts Use the Records
No single expert covers every question in a birth injury case. Obstetric, midwifery and neonatal questions go to experts in those fields, and an independent clinical opinion depends entirely on having the full record to read.
Breach of Duty
The liability expert compares the timeline with accepted practice at the time and says whether care fell below a reasonable standard. They rely on the trace, the notes and the guidance in force then.
Causation and Later Consequences
Causation asks whether better care would have changed the outcome, the question discussed in causation in complex medico-legal cases. Where a birth injury has left a limb or nerve injury, a surgeon can assess the injury and its long-term effect, as covered in nerve injuries in the upper limb. Reports follow CPR Part 35.
Why Timing Matters
For a child, the usual three-year limitation period generally does not begin until the 18th birthday, but different rules can apply to a parent’s own claim or where capacity is affected. A solicitor should confirm the position in each case.
Evidence is a separate concern. Staff memories fade and files can be mislaid, so securing the records early protects the claim even when there is no immediate deadline.
Frequently Asked Questions
Why are labour records so important in a birth injury claim? They are the contemporaneous account of the monitoring, assessments and decisions during labour. Without them, a court has little objective way to judge whether care was reasonable.
What is the difference between the CTG and the partogram? The CTG is a continuous trace of the baby’s heart rate and contractions. The partogram is a chart of labour progress and observations at set intervals.
What if the CTG trace cannot be found? Its absence is serious. The case may then rely on written entries and witness accounts, and the missing trace is likely to be questioned.
Can parents see the labour records? Yes. Patients and, for a child, those with parental responsibility can usually request the records. A solicitor can request the full file, including the original CTG.
Does an incomplete record prove negligence? No. Poor record keeping is not the same as poor care, but it can make the care harder to defend or to explain.
Related Reading
- Medical records as evidence in a negligence claim
- How nerve injuries in children are assessed and managed
- Balance of probabilities, the standard behind medico-legal opinions
Solicitors weighing a birth injury claim can see how to instruct Prof. Hindocha where the question involves a nerve or limb injury, or explore the wider medical negligence expert witness service.
This article is general information about the role of labour records in birth injury claims and is not a substitute for legal or medical advice on a specific case.