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Addendum 1: Principles to be used in Determining Policy Regarding the Retention and Storage of Essential Maternity Records

British Paediatric Association
Royal College of Midwives
Royal College of Obstetricians and Gynaecologists
United Kingdom Central Council for Nursing, Midwifery and Health Visiting

Joint Position on the Retention of Maternity Records

  1. All essential maternity records should be retained. ’Essential’ maternity records mean those records relating to the care of a mother and baby during pregnancy, labour and the puerperium.

  2. Records that should be retained are those which will, or may, be necessary for further professional use. ’Professional use’ means necessary to the care to be given to the woman during her reproductive life, and/or her baby, or necessary for any investigation that may ensue under the Congenital Disabilities (Civil Liabilities) Act 1976, or any other litigation related to the care of the woman and/or her baby.

  3. Local level decision making with administrators on behalf of the health authority must include proper professional representation when agreeing policy about essential maternity records. ’Proper professional’ in this context should mean a senior medical practitioner(s) concerned in the direct clinical provision of maternity and neonatal services and a senior practising midwife.

  4. Local policy should clearly specify particular records to be retained AND include detail regarding transfer of records, and needs for the final collation of the records for storage. For example, the necessity for inclusion of community midwifery records.

  5. Policy should also determine details of the mechanisms for return and collation for storage, of those records which are held by mothers themselves, during pregnancy and the puerperium.

List of Maternity Records to be Retained

   6.       Maternity Records retained should include the following:
   6.1    documents recording booking data and pre-pregnancy records where appropriate;
   6.2    documentation recording subsequent antenatal visits and examinations;
   6.3    antenatal in-patient records;
   6.4    clinical test results including ultrasonic scans, alpha-feto protein and chorionic villus sampling;
   6.5    blood test reports;
   6.6    all intrapartum records to include, initial assessment, partograph and associated records including cardiotocographs;
   6.7    drug prescription and administration records;
   6.8    postnatal records including documents relating to the care of mother and baby, in both the hospital and community settings.