No midwife ever wants to encounter a complication at a birth, but they are a reality of practice. When things move quickly, the last thing on your mind may be documentation — yet the chart you write after a complication can be one of your strongest tools for protecting yourself legally and supporting your client’s ongoing care. Memory fades quickly under stress. A clear, complete, and objective record ensures that the facts are preserved and can be relied upon later if needed.

General Principles of Documentation After a Complication

When you sit down to chart, keep these guidelines in mind:

• Document promptly. Chart as soon as possible after the event while details are fresh.
• Stay objective. Record what you observed, what you did, and what the outcomes were. Avoid speculation, opinions, or emotional language.
• Keep it clear and chronological. List events in the order they happened with time stamps whenever possible. Check your phone for the time you called 911, or time stamps on any photos that were taken.
  • Some midwives start an audio recording on their phone as soon as a complication is recognized, then dictate when meds are given, positions are changed, etc. with the intent to use this to piece together the chart later. Just remember: in Washington State, you need consent from everyone in the room before recording.
• Use professional language. Do not write defensively or assign blame; let the facts speak for themselves.

What to Include in the Chart

1. Initial recognition of the complication

• Time the complication was first noted
• Signs or symptoms observed
• Who was present at the time and what was communicated

2. Assessments

• Maternal vital signs, fetal heart tones, and other relevant findings
• Changes from baseline assessments
• Frequency of ongoing monitoring and reassessment; if your plan is to check again more frequently than your usual protocol, say so

3. Interventions

• Detailed description of actions taken (e.g., maneuvers, medications, oxygen)
• Exact time of each intervention, if possible
• Client’s response to the intervention

4. Consultations and transfers

• Time and method of contacting EMS, physician and/or hospital
• What information was communicated and to whom
• Documentation of client/family consent for transfer

5. Client communication

• Information explained to the client and family
• Client’s questions, understanding, and responses
• Any informed consent or refusal during the complication

6. Outcomes

• Maternal and newborn status at each key interval
• Events during transport or upon hospital arrival
• Any follow-up of debriefing documented after the event

Common Pitfalls to Avoid

Even experienced midwives can slip into habits that weaken their charting. Avoid these pitfalls:

• Writing vague notes: “Baby not doing well” instead of specific vital signs
• Skipping time stamps for key interventions
• Recording only subjective and objective findings without an assessment and a plan
• Adding retrospective notes without labeling them clearly as “late entries”

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Example: Poor vs. Strong Documentation

Poor example:

“Client bled a lot, gave Pitocin, transferred.”

Stronger example:

“At 8:14 pm, client experienced brisk vaginal bleeding estimated at 600ml within 10 minutes. Fundus boggy. Uterine massage initiated, 10 units IM oxytocin administered at 8:16 pm. Bleeding decreased but remained heavy. At 8:19 pm, EMS called; Dr. Smith at County Hospital notified of postpartum hemorrhage. Client and partner informed and consented to transfer. EMS arrived at 8:27 pm; report given en route. Client stable, BP 104/66, pulse 102.”

The second note paints a clear picture of events, shows timely and appropriate interventions, and demonstrates good communication with client and receiving providers.

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Protecting Yourself and Supporting Your Client

Thorough documentation isn’t just about covering yourself legally. It also helps ensure continuity of care, especially when another provider takes over. Your chart is evidence that you acted according to standards of care and kept the client’s safety at the center of your response. In the event of a review, complaint, or legal claim, your records become the most reliable account of what actually happened.

Complications are part of midwifery practice. What matters most is how they are recognized, managed, and documented. A well-written chart preserves the facts, demonstrates professionalism, and supports both your client and your practice.

We’d love to hear from you: What strategies do you use to ensure your charting is complete and accurate after a complication?

The information provided through this activity is for educational purposes only. This information is intended to provide general guidelines for risk management and those involved in claim process. It is not intended and should not be construed as legal or medical advice.