Records and paperwork for maternal health care and babies

When you are having a baby, there are various records and documents that need to be accessed, created or completed. Examples include your medical records, hospital pre-admission forms, official records such as birth certificates, and your baby’s immunisation records. In many cases it will be up to you, as the pregnant woman or new parent, to keep track of this paperwork.

Before pregnancy#

When you are preparing for pregnancy, it is a good idea to visit your doctor for a check-up.

If you do not have a regular doctor, planning for a baby is a good time to find one you can build an ongoing relationship with. If you are seeing a doctor for the first time, ask for your medical records from previous doctors so your new doctor has full access to your medical history.

Your maternity record#

Many maternity services provide a printed maternity record — a single, consistent document of your pregnancy care and progress. A record like this:

• Keeps your complete pregnancy information in one place, reducing risk.
• Improves the consistency of the information you receive.
• Improves communication between your care providers, providing continuity from one provider to the next.

If your maternity service offers such a record, take it to each of your antenatal appointments, and use it to stay involved in decisions about your care.

Developing a birth plan#

Once you understand your birthing options, you may like to develop a birth plan. This is a document that outlines your treatment preferences so that, when the time comes, your doctor, obstetrician and midwives are clear about your choices. It might include decisions about your position in labour, pain relief, or who you would like in the room with you.

When developing your birth plan, consider the following:

• Some options might not be available, depending on your hospital and your health.
• Have a plan B. If things do not go as planned, have a back-up preference that you understand and have researched.
• If you prefer not to have your baby in a hospital, be aware this can limit your specialised care options if something goes seriously wrong during labour.
• You can change your mind during the pregnancy. However, some decisions may be taken out of your hands if your health or your baby’s health is at risk.

Packing for hospital#

Because labour can begin at any time in the final weeks of pregnancy, many women pack a hospital bag ahead of time, including pyjamas, basic toiletries, and items for the baby such as clothes and nappies.

For paperwork, it is also a good idea to include:

• Your address book and important phone numbers, including your doctor’s name and number.
• Your birth plan.
• Any insurance or health-cover details and pre-admission paperwork required by the hospital.

Registering your baby’s birth#

When your child is born, the hospital, medical facility or midwife will give you a birth registration form. You use this form to register your baby’s birth and apply for a birth certificate.

A birth certificate is a proof-of-identity document. It is the first step in establishing identity and is often required for official purposes, such as claiming benefits and enrolling a child in childcare and school.

When registering a birth, both parents usually need to:

• Complete the form in full.
• Sign it in front of a witness (who signs on the same day they witness the parents’ signatures).
• Provide payment for any certificates ordered.

There is generally a deadline for lodging the completed form with the relevant births registry, and a birth must be registered before a certificate can be issued. Check the requirements that apply where you live.

Your child’s health record#

In many places, parents are given a personal child health record when their baby is born. This is a booklet for parents to keep and use to record their child’s milestones, health, growth, development and immunisations. It often has space to add personal details, photos and important documents.

When you visit a healthcare professional with your child, take the booklet so they can add new information. It is also useful to take it to your childcare centre, kindergarten or school.

Immunisation records#

An immunisation record typically includes your child’s name, date of birth, address, and the name and date of every vaccine they have received.

In many places it is a requirement to provide an immunisation history statement when you enrol your child in an early childhood service (such as long day care, kindergarten, family day care and occasional care) or primary school. Staff keep a copy of the statement on file.

• To enrol in an early childhood service, parents often need to show that the child is up to date with all the immunisations they can receive. If the child receives further vaccines after enrolling, the parent provides an updated statement to the service.
• To enrol in primary school, an immunisation history statement may still be required, but in some places it does not need to show the child is up to date for the child to be enrolled.
• If a child has not been vaccinated for any reason, a statement may still be required. It will show which vaccinations are overdue and note that the child is not immunised.

Schools need to be aware of the immunisation status of students so they can follow exclusion processes in the case of an outbreak.

Key points#

• It will often be up to you as the parent to keep track of your pregnancy and baby paperwork.
• A consistent maternity record keeps your pregnancy information in one place and improves communication between care providers.
• A birth must be registered before a birth certificate can be issued.
• An immunisation history statement is often required to enrol a child in childcare or school.