Clinical Record Forms

Antenatally, Ontario midwives and physicians use the Ontario Perinatal Record produced by the Ministry of Health and Long-Term Care. For labour and postpartum, the AOM created out-of-hospital clinical record forms, with the intention that they

  • embody midwifery values;
  • facilitate consistent charting by midwives;
  • contribute to safe care and communication of care planning; and
  • protect midwives in the unlikely event of future claims.

The package consists of:


Labour: First Stage and Labour: First Stage (Page __ of ___)

Non-randomized trials have shown potential benefits of the use of the partogram (pictoral overview of progress, ease of recording, auditing of care, training of clinicians, and transferring of care), however high-quality evidence is not available. The Cochrane Systematic Review concludes that the decision to use a partogram should be locally determined, while the World Health Organization (WHO) recommends the use of the partogram and the CMO encourages its use. The AOM clinical record forms have historically included a partogram. As a result, the partogram recommended by the WHO has been included for those midwives who choose to use it; it does not distinguish between primiparous and multiparous clients.

Charting should be initiated on the partogram when the client is in active labour and 4 cm dilated.  

Alert and Action lines are printed on the partogram, 4 hours apart.  A client’s labour graph crossing the Alert line is a visual prompt to consider paying closer attention to the progress of the labour; crossing the Action line is a visual prompt to consider taking action to encourage the progress of the labour. Primiparous clients’ labour graphs will cross the Alert line more often than multiparous clients’ labour graphs.

The use of the partogram is more effective when a guideline is used to outline what a midwife might do in these two circumstances.  Practices may consider discussing and agreeing upon labour management actions that they would take specific to their community.

Practices may want to discuss what “screened for S&S (signs and symptoms) of infectious disease” refers to in their context.  This may change with outbreaks of infectious diseases, or may be different regionally.

Labour: Second Stage (Page 1 of ___) and Labour: Second Stage (Page __ of __)

There are no instructions for this section.

Immediate Postpartum/Third Stage/Labour Summary

This form includes client position at time of birth and fetal position at birth, which is tracked in BORN.

If more room for charting is necessary, as in a postpartum hemorrhage, a Narrative Note and/or the Client Transfer Record may be used;

An area to assist in tracking the sterilization of instruments has been included.

Perineal Repair/Instrument Record/Departure

An area to assist in tracking the sterilization of instruments has been added;

The departure section of the form can be used to document the midwives departing from the client’s home or the client departing from the birth centre or clinic. If the newborn departure time is different from the client departure time, it can be charted on page 2 of the Immediate Newborn Care and Summary form.

Immediate Newborn Care and Summary, and Newborn Narrative/ Informed Choice Discussions

The form includes skin-to-skin and breastfeeding attempts fields – which are tracked in BORN.

A weight percentile for gestational age field assists in identifying SGA and LGA babies and implementing a pediatric consultation or a hypoglycemia protocol as necessary.  Some ancestry-specific birthweight charts have been developed or midwives may choose to use the basic Canadian birthweight charts as resources. BORN will be providing Canadian data to GROW (Gestation Related Optimal Weight) UK to develop customizable growth curves for pregnancy that are Canadian specific. These curves may offer further options for ancestry-specific normal birthweight assessments. This tool is not currently available. Midwives may refer to http://www.gestation.net/ or the BORN Bulletins for updates. Practices/birth centres may choose to:

  • include a copy of the birthweight chart in each out of hospital birth package which would be reused;
  • post the birthweight chart (especially for birth centres and practices that offer clinic births); or
  • refer to the birthweight chart online.

It is expected that midwives will have documented any prenatal informed choice discussions about newborn medications on a prenatal narrative note and that the level of documentation will reflect the level of risk associated with the choice the client makes.  Any repeat ICDs should be charted on the Narrative section on page 2 of the form.

Additional detail on newborn exam or additional assessments can be charted on the Narrative section on page 2 of the form.

The client and newborn charts only need to be separated if practices plan to destroy the client chart prior to destroying the newborn chart. These records are designed either to be separated without duplicate charting, or to remain together in one file, depending on the protocol in the practice.

Newborn Summary and Postnatal Care (Page 1 and 2)

Routine screening for hyperbilirubinemia may be charted on the first page.  Follow-up testing may be charted on the Narrative on the second page.

If newborn screening for congenital heart defects using oxygen saturation is routine in the midwives’ community, it can be charted under the Notes section on the first page or on the Narrative section on the second page.

Tick boxes are included for routine newborn medication and tests for quick reference. Details regarding medication administration or tests may be charted on the birth records or on other forms such as the hearing screen form.

Client Summary and Postnatal Care (Page 1 and 2)

The date and time of hospital admission and discharge is included for use (if relevant) to assist in BORN data entry.

Narrative Notes

This can be used for any narrative that does not fit on the relevant record.

Assessment Record (Page 1 and 2)

Some practice groups may choose to use this record to document early labour assessments or other in-person clinical assessments, for example assessment of prelabour rupture of membranes.

An area to assist in tracking the sterilization of instruments (i.e. a speculum) has been added.  If relevant, record the tracking #, sterilization log # and sterilization date.

Some FHR Assessment fields may not be relevant if the midwife is completing an assessment using auscultation.

Some fields from this form are repeated on the Labour First Stage form.  When a client is in active labour on first assessment the midwife would skip the Assessment Record and start charting on the Labour First Stage form.

Client Transfer Record and Client Transfer Record Narrative

Some fields on this form may not be applicable depending on when the transport takes place.  
This form may be copied and used as a summary for the receiving hospital physician.
It is often difficult to chart during an emergency so page 2 of this form is entirely space for narrative to facilitate contemporaneous charting. There is a space at the bottom of page one to indicate if the form is filled out as a late entry (i.e. on arrival at hospital).

Newborn Transfer Record and Newborn Transfer Record Narrative

This form may be copied and used as a summary for the receiving hospital physician;

It is often difficult to chart during an emergency so page 2 of this form is entirely space for narrative to facilitate contemporaneous charting. There is a space at the bottom of page one to indicate if the form is filled out as a late entry (i.e. on arrival at hospital).

Newborn Resuscitation Record (Page 1 and 2)

This form will be used infrequently so midwives may consider using it in skills drills to familiarize themselves with the format.

Prompts have been incorporated into the form to remind midwives of steps in resuscitation. Canadian guidelines are expected to change when the 7th edition of the NRP handbook is released. At that time the meconium section of this form may be removed or updated.

The ETT dose of epinephrine is from the Canadian Supplement to the NRP handbook. The dose differs slightly in comparison to the American dose.

Midwives may choose to document repeated attempts at intubation in the Narrative section or practices may choose to include duplicate copies of this form for extra charting.

Signature Page

Everyone who provides care to the client should sign this form. This includes midwives, students and birth centre aides.

This form may be in the client file rather than in the birth package for home births. For births at the birth centre, it may also need to be in the birth record package so that birth centre aides can sign it.

    Assembly Instructions

    There are two options for each form:

    1. Forms with greyscale reminders for date and time formats (watermark); and
    2. Identical forms without greyscale reminder (no watermark) because some photocopiers make the reminders look darker, interfering with charting. The forms are otherwise identical.  

    The AOM recommends printing and assembling the forms in the following way:

    Normal Birth Package

    • Front: Labour: First Stage (with partograph); Back: Labour: First Stage (with Fetal Assessment/ Contractions/ Maternal Assessment)
    • Front and back, for longer labours: additional copies of Labour: First Stage (Page _ of _) (with Fetal Assessment/ Contractions/ Maternal Assessment)
    • Front: Labour: Second Stage (Page 1 of _); Back: Labour: Second Stage (Page _ of _)
    • Front: Immediate Postpartum/ Third Stage / Labour Summary; Back: Perineal Repair/ Instrument Record/ Departure
    • Front: Immediate Newborn Care and Summary; Back: Newborn Narrative/ Informed Choice Discussions
    • Front: Newborn Summary and Postnatal Care (Page 1); Back: Newborn Summary and Postnatal Care (Page 2)
    • Front: Client Summary and Postnatal Care (Page 1); Back: Client Summary and Postnatal Care (Page 2)

    Extra Forms

    • Front: Assessment Record (Page 1); Back: Assessment Record (Page 2)
    • Front: Client Transfer Record; Back: Client Transfer Record Narrative
    • Front: Newborn Transfer Record; Back: Newborn Transfer Record Narrative
    • Front: Newborn Resuscitation Record (Page 1); Back: Newborn Resuscitation Record (Page 2)
    • Front and Back: Narrative Notes
    • Signature Page (may be in client file rather than in birth package)
    • Extra First and Second Stage forms.

    A customizable version of these forms is available if the practice has access to the software Adobe InDesign.

    For any questions, contact Cara Wilkie, Quality and Risk Management Manager, 416-425-9974 / 1-866-418-3773 ext. 2246.

    Development and References

    The forms were developed incorporating the feedback of midwives, the CMO, HIROC, the MEP, the Ottawa Birth and Wellness Centre, the AOM’s Quality, Insurance and Risk Management Committee, and the Toronto Birth Centre. The forms were revised using the following sources: