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Key takeaways

• Maternity notes are your pregnancy record, either paper or digital.
• They help all healthcare professionals understand your journey.
• Your notes contain medical history, test results, and baby's growth.
• You have the right to access your records during and after pregnancy.

What are maternity notes?

Maternity notes are your main record throughout your pregnancy journey. They are also known as pregnancy notes or handheld notes. These notes can be a paper book or folder, alternatively, they can be in an electronic form.

You will receive your notes, or instructions on how to access them digitally, at your first appointment. This is called the booking appointment.

It is important to take your notes to every antenatal appointment or any other healthcare appointment during your pregnancy.

Your midwife or doctor should record every appointment, test, or scan in your notes. They also record the care you receive during labour, birth, and the early period after birth. This helps all healthcare professionals understand your pregnancy needs so they can provide care individualised to you.

A guide to what's inside your notes

Your maternity notes will contain practical information like appointment times, and phone numbers for your midwife team, the birthing facilities and 24 hour helplines. They hold important information about you and your baby, and include your contact details and your medical history.

Any family history that might be relevant to your pregnancy is also noted. Information about any previous pregnancies and births will also be found here. You can request for this information to be discreet if it will make you feel more comfortable.

Information is gathered at your antenatal checks and summarised in your notes. This includes results from blood tests, other investigations, and ultrasound scans. Your baby's growth assessment and any health concerns during your pregnancy are also recorded.

Your notes will also include your birth plan, details of your labour care, and postnatal care. They may also contain leaflets and extra information.

Understanding common terms and abbreviations

Understanding test results

Your notes will show results from urine tests. These tests check for protein, sugar and some other markers.

A high level of protein could be a sign of a condition that affects your blood pressure (pre-eclampsia). A high level of sugar could be a sign of pregnancy-related diabetes (gestational diabetes).

• If your notes say 'NAD' or 'Nil', it means nothing abnormal was detected.
• If a small amount of sugar or protein is found, it might be noted as 'Tr' (trace).
• A greater amount of sugar or protein might be indicated by '+', '++', or '+++'.

The baby's heartbeat or activity is also recorded. This is measured by listening to your baby and gently feeling your abdomen after 20 weeks of pregnancy.

• If your midwife has listened to your baby's heartbeat you might read ‘fetal heart heard’ (FHH) or ‘fetal heart beat regular’ (FHHR)
• Sometimes, it can be tricky to hear the heartbeat, perhaps because of your baby's position. If this happens, your midwife might write ‘foetal heart not heard’ (FHNH).
• If your midwife has felt your baby move, they may note this as ‘foetal movements felt’ (FMF).

Understanding your baby's position

Your midwife will also record your baby's position by feeling your belly, with your permission. This description involves three main aspects: lie, presentation, and position.

Lie describes how your baby is lying in relation to your spine.

A longitudinal lie (L) means your baby is parallel to your spine, either head-down or bottom-down. An oblique lie (O) means your baby is lying diagonally across your womb. A transverse lie (T) means your baby is lying sideways across your womb.

Presentation shows which part of your baby is closest to the birth canal. A cephalic presentation (C), also known as vertex presentation, means your baby is head down. A breech presentation (B or Br) means your baby is bottom or feet first.

Position gives a more detailed description of the way your baby's presenting part is facing in your pelvis. This is often noted using a combination of letters.

The first letter indicates the side of your pelvis (L for left, R for right). The second letter (O) is for the back of your baby's head (occiput) in cephalic presentations, or (S) for your baby's bottom (sacrum) in breech presentations.

The third letter indicates direction:

• (A) for towards your belly (anterior)
• (P) for towards your back (posterior)
• (T) for towards your side (transverse)

For example, 'LOA' stands for Left Occiput Anterior. This means the back of your baby's head is on your left side and facing your belly.

Understanding engagement

Engagement of your baby's head in your pelvis is also recorded. If your baby's head has not yet moved down into your pelvis, this may be noted as 'not engaged' (NE). When it has moved down, it is noted as 'engaged' (E).

Engagement might also be recorded in fifths, showing how much of the baby's head the midwife can feel. For example, 4/5 means most of the head is above the pelvic brim, while 2/5 means most of the baby's head has moved into the pelvis.

Engagement often happens earlier in a first pregnancy. It is important to remember that every pregnancy is different for every person.

Your rights to access and share your records

You have the right to see your own health records. This is a right that is protected by law.

Your maternity records are open and active throughout your pregnancy and birth. Your records begin at your booking appointment, which is your first main appointment with your midwife.

If your area uses paper records, you will be given a copy at this appointment.

You should keep these records with you throughout your pregnancy and birth. These are normally stored securely with the organisation following your maternity care.

If your area uses electronic records, you will be told how to access them. You can also decline digital notes and ask for paper notes.

It is important to keep your notes in a safe place:

• Take them with you to all your appointments.
• Remember to have them with you when labour starts.
• Take them with you if you are away from home for any length of time.

This helps ensure all health professionals know your pregnancy history.

Maternity records are held by the NHS Trust or Board for 25 years after the birth. If you use private care, your care provider will keep your notes. They will probably offer you a copy.

After your baby is born and discharged from the hospital, the hospital keeps your paper records. If you gave birth at home with NHS care, the midwife will give your records to the local hospital. If you have electronic records, you should ask your Trust or Board how you can access them once your maternity care has finished.

How to get a copy of your notes

If you want a copy of your entire medical record, you can make a formal written request for your information. This is called a subject access request.

This request should be sent to the medical records manager of the NHS Trust or Board. Their address should be available on their website.

Your request should be dealt with within one month of being received. You normally do not need to pay to see your records.