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The labour record is one woman’s whole labour on one page: the Delivery record at the top, then the Labour chart, then Babies. The chart has its own page — The labour chart — and so do the births: Babies and birth records.

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What you’re looking at

Her name at the top, with Labour record, her gestation and her EDD underneath. Labour Ward at the top right goes back. Three blocks follow: Delivery record, then the Labour chart — a cervicograph and an observation matrix — then Babies, with a count and one row per baby. Babies appears only once a delivery record exists, since a birth is recorded against the labour. The Delivery record card carries a state badge — Not started, Draft, Recorded, unsigned or Signed — and a button reading Start delivery record or Open record. Before one exists the card says: “Nothing is claimed about this labour yet. Starting the record is what puts her on the Labour Ward board.”

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The three states, and why they are separate

Completing the record is a deliberate act with its own button, so a record never becomes a clinical claim as a side effect of typing into a field.

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Write up the delivery

Select Open record. The sheet is headed Delivery record and notes: “one labour, one record — twins are two birth records against this one.”
1

Labour

Onset, Mode of delivery, Labour started and Time of birth. Induction method appears only when labour was induced. The stage durations — First stage, Second stage, Third stage — are in minutes.
2

Third stage

Placenta, Estimated blood loss in ml, and Oxytocic given.
3

Perineum

Perineum, Episiotomy, and Tear degree — which appears only where the perineum tore.
4

Outcome and attendant

Complications is a comma-separated line, Attendant picks a member of staff, and Notes is free text.
5

Save it as a draft, or complete it

Save draft keeps it open with nothing claimed — “Draft saved”, “Nothing is claimed yet — complete it once you have the time, the mode and how labour started.”Complete record promotes it, and confirms Delivery recorded — “It is the record of this birth. Sign it when you are ready to attest it.”

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Sign it

Sign record appears on a saved, completed, unsigned record — and on the board row. Confirm at Sign this delivery record?: signing “attests it as the clinical record of this birth, under your name and with the time you signed. It can no longer be amended afterwards; a correction then has to be recorded as one.”
Sign is disabled while you have unsaved changes, and the page says Save your changes before signing. Signing over unsaved edits would attest something nobody can read back. Save first, read what stands, then sign.
A signed record is read-only throughout, and the banner says why: “This is the signed clinical record of the birth. It can no longer be amended — record an amendment rather than changing it.” Signing also closes the pregnancy record, so she leaves Today’s Clinic — a woman who has given birth is not an antenatal patient. The outcome is taken from the births you recorded: Live birth if any baby was born alive, Stillbirth if none was. She appears in the Antenatal Register with that outcome, and on Postnatal for her and her babies’ checks. The confirmation says so.
If no birth has been recorded against the delivery, the pregnancy record is left open and you are told. There is no outcome to state, and a pregnancy cannot be reopened once closed — so it waits for the birth rather than being closed as a guess.

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Retract a record that should never have existed

At the bottom of the sheet, Mark as entered in error retracts the whole delivery record — for a labour filed against the wrong woman, or a duplicate. It is offered on a signed record too, because refusing it would leave a signed claim that a woman gave birth when she did not, with no way out. It asks for a reason, which becomes part of the record, and it says what it will and will not move: the record stays on file read-only, drops out of the delivery and coverage figures, and “Nothing else moves. The pregnancy record, the labour observations, the ward admission and the theatre case stay exactly as they are.” Any birth still recorded against the labour has to be retracted first. The full sequence, the refusals and what a signed record additionally needs are on Retract a delivery or birth record.

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Who can do this

Signing is a separate permission from recording on purpose — writing up a birth and attesting to it are different acts. Retracting rides the recording permission, because whoever may say a birth happened may say it did not; retracting a signed record needs signing authority as well, because unmaking an attestation takes the same authority as making one.

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Check it worked

  • The card’s badge reads Recorded, unsigned after Complete record, and Signed afterwards.
  • Her row on Labour Ward shows the same state.
  • Once a Time of birth is on the record, the board’s In labour for column reads Born ….

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If something goes wrong

“Save it as a draft until you have those.” Time of birth, Mode of delivery and Onset are what completing the record claims.
Labour started is later than Time of birth. Check both.
Time of birth is ahead of now. Check the time as well as the date.
Set Onset to induced, or clear Induction method.
Set Perineum to a tear, or clear Tear degree.
Select Complete record, check what it says, then Sign record.
Somebody signed it while your sheet was open. Reload — a signed record cannot be amended.

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FAQ

Not by editing it — the record is closed, and a correction is recorded as an amendment. If the record should never have existed at all, that is a different act: Mark as entered in error, which needs signing authority on a signed record. See Retract a delivery or birth record.
One labour is one delivery record, and each baby is a birth of its own. Twins are Baby 1 and Baby 2 in the Babies section — see Babies and birth records.
No. Closing the pregnancy record is a separate act with its own permission — see Open, re-date and close a pregnancy record.
She appears on Postnatal, with her four WHO contacts and a row for each baby. Nothing else has to be done to put her there.
Yes — that is what a draft is for. It claims nothing and needs no time or mode.
Active staff at your hospital.