Records and paperwork for maternal health care and babies

When you are having a baby in Victoria, there are various records and other documents that need to be accessed, created or completed. Your medical records, hospital pre-admission forms, state health records such as birth certificates and your baby’s immunisation records are examples. It is important to remember that in many cases, it will be up to you as the pregnant woman or new parent to keep track of this paperwork.

Your health records

When you are preparing for pregnancy, it is a good idea to visit your general practitioner (GP) for a check-up. If you do not have a GP you regularly see, planning for a baby is the perfect time to find one with whom you can establish an ongoing relationship.

If you are seeing a doctor for the first time, it is a good idea to request your medical records from previous doctors you have seen. That way, your new doctor will have detailed access to your medical history.

Victorian Maternity Record

The Victorian Maternity Record (VMR) is a Victorian Government initiative designed to provide pregnant women with a consistent printed maternity record of their pregnancy care and progress.

The VMR encourages you to become involved in decisions regarding your maternity care and helps improve communication between your maternity care providers.

The benefits of the VMR are that it:

• reduces risk by having your complete pregnancy records in one place
• improves the consistency of information you will receive
• improves communication between your care providers
• provides continuity in documentation from one healthcare provider to another.

The VMR is available from most public maternity providers and should be taken to each of your antenatal appointments.

Developing a birth plan

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

When developing your birth plan, consider the following:

• Some birthing 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 your preference is not to have your baby in a hospital, this will limit your specialised care options if something goes seriously wrong during your labour.

Remember that even though you have developed a birth plan, you can change your mind during the pregnancy. However, some decisions may be taken out of your hands if your health or the health of your baby is in jeopardy.

For more information see the Pregnancy and Birth Care Options fact sheet.

What information to take with you to hospital

Knowing that labour can come on at any time in the final weeks of pregnancy, many women prepare by packing a hospital bag ahead of time that includes pyjamas, basic toiletries, and things for the baby such as clothes and nappies. As far as paperwork goes, it is also a good idea to include:

• your address book and important phone numbers, including your GP's name, address and telephone number
• your Medicare card
• your health care card (if you have one)
• private health insurance information (if applicable)
• any pre-admission paperwork required by the hospital
• your birth plan.

Your baby’s birth registration

When your child is born, the hospital, medical facility or midwife will give you a Birth Registration Statement (BRS). You can then use the BRS to register your baby’s birth and apply for a birth certificate.

A standard 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 government benefits and enrolling a child in childcare and school.

When registering a birth, make sure both parents:

• complete the BRS in full
• sign the BRS in front of a witness (who must sign the form on the same day they witness the parents’ signatures)
• provide payment for any certificates ordered.

You must lodge the completed BRS to the Victorian Registry of Births, Deaths and Marriages within 60 days of the baby’s birth. A birth must be registered before a certificate can be issued.

Your child’s health record

The My Health and Development Record (a green booklet) is given to Victorian parents in hospital when their baby is born. This document replaced the Child Health Record in 2011. The My Health and Development Record is designed for parents to keep and record their child's milestones, health, growth, development and immunisations. It also allows parents to add personal details about their child's development, with space for photos and plastic sleeves for important documents.

When you visit a healthcare professional with your child, it is a good idea to take the booklet with you so the healthcare professional can add new information.

Remember to take your child’s booklet to:

• your maternal and child health nurse
• immunisation appointments
• your doctor
• other healthcare professionals
• hospital or emergency departments
• your dentist
• your community health centre
• your childcare centre, kindergarten or school.

Immunisation History Statements

Immunisation History Statements from the Australian Immunisation Register (AIR) include your child’s name, date of birth, address and the name and the date of all vaccines your child has received. It is a legal requirement to provide an Immunisation History Statement when you enrol your child in an early childhood services (including long day care, kindergarten, family day care and occasional care) or primary school in Victoria. Staff will keep a copy of your child's statement on file.

To enrol in an early childhood service parents need to provide an Immunisation History Statement that shows the child is up to date with all immunisations they can receive. If/when a child receives a vaccine/s after enrolling and while attending an early childhood service, the parent must provide an updated Immunisation History Statement to the service.

To enrol in primary school, an Immunisation History Statement from the Australian Immunisation Register (AIR) is still required. However, the statement does not need to show that the child is up to date with vaccines for the child to be enrolled. If your child has not received vaccines for any reason, they will still require an Immunisation History Statement from the AIR to enrol in a primary school. The statement will show their vaccinations are overdue, and will state that they are not immunised. Schools need to be aware of the immunisation status of primary school students to follow exclusion processes in the case of an outbreak.

Where to get help

• Your GP (doctor)
• Midwife
• Obstetrician