How Parents Can Document Potential Birth Injury Evidence at Home and in Medical Records

When a baby is born, parents expect the hospital and medical team to ensure a safe and healthy delivery. But when things go wrong — whether due to negligence, miscommunication, or poor decisions in the delivery room — the results can be devastating.

Birth injuries can lead to long-term complications for a child and emotional trauma for the entire family. And in many cases, parents are left confused and unsupported, unsure how to advocate for their baby or prove what actually happened.

If you suspect your child suffered an injury during labor or delivery, this guide will walk you through the steps to document the injury at home, understand your legal rights, and begin building a case for accountability and compensation.

 

Understanding the Importance of Birth Injury Documentation

Birth injury documentation serves two critical purposes:

1. It can provide vital medical insight to help physicians track and treat developing conditions.
2. It offers legal evidence that may be necessary in the event of a medical malpractice claim.

Why Medical Records Are Not Enough

Many parents assume that if something serious happened during delivery, it will be reflected in the hospital’s records. Unfortunately, that is often not the case. Medical staff may downplay, misrecord, or omit critical details. Some notes may be vague, incomplete, or overly clinical, failing to reflect the severity or immediacy of an injury.

For example, a newborn may have been bruised during a forceps delivery, yet the hospital record may only say “delivery assisted with instrumentation” with no mention of the physical effects.

Why Home Documentation Matters

Parents are the primary witnesses to their baby’s postnatal condition. You see every movement, cry, and moment of discomfort — often long before doctors take a closer look. Your personal records help to:

• Establish a clear timeline of when symptoms emerged.
• Capture evidence that may not appear in medical charts.
• Provide a detailed account that can be reviewed by legal or medical professionals later.

 

Common Types of Injuries Sustained During Birth

Before you begin documenting, it’s important to understand what types of injuries could occur during labor and delivery. These vary in severity and long-term consequences.

Physical Injuries

1. Bruising or swelling, especially from forceps or vacuum use
2. Fractures, particularly of the clavicle or shoulder
3. Facial paralysis caused by nerve damage during delivery
4. Brachial plexus injuries affecting the arms and hands

Brain and Oxygen-Related Injuries

1. Hypoxic-ischemic encephalopathy (HIE) — brain injury from lack of oxygen
2. Cerebral palsy linked to birth complications
3. Intracranial hemorrhage, or bleeding in the brain

Developmental Delays or Behavioral Issues

1. Trouble feeding or latching
2. Seizures
3. Lethargy or low muscle tone
4. Lack of responsiveness to stimuli

Documenting signs of these injuries — especially when they appear within hours or days of birth — is essential for medical diagnosis and legal review.

 

What You Can Document at Home

You don’t need special tools or training to begin collecting evidence. A combination of photos, notes, videos, and timelines can be incredibly effective.

Documenting Visible Symptoms

If your baby has bruises, swelling, unusual limb positioning, facial drooping, or skin marks, photograph them as soon as you see them. Be sure to:

• Take clear, unedited pictures.
• Include an object for scale (like a ruler or pacifier).
• Use timestamps, or record the time and date manually alongside each photo.

Documenting Behavior and Development

Look for signs like:

1. Excessive crying or arching of the back
2. Difficulty latching or feeding
3. One side of the body not moving as much as the other
4. Floppiness or muscle stiffness
5. Lack of eye contact or responsiveness

These behaviors can indicate underlying nerve damage or neurological trauma.

Keeping a Daily Journal

Start a written journal or digital log and include:

1. Dates and times of symptoms
2. Specific behaviors you noticed
3. Your observations on feeding, sleep, and reactions
4. Notes from pediatric visits or phone consultations

Writing daily — even short entries — will help establish patterns and provide context for any abnormalities.

 

How to Take Legally Useful Photos and Videos

Photos and videos can play a key role in supporting your case, but they must be taken with care.

Best Practices for Photos:

• Take photos immediately after noticing symptoms or injuries.
• Use natural light where possible and avoid filters.
• Include reference items and context (e.g., both arms in the photo to show asymmetry).
• Save originals and avoid editing.

Best Practices for Videos:

• Capture moments like feeding issues, lack of movement, or seizures.
• Narrate what you’re recording (e.g., “Tuesday morning at 9:00 AM, baby unable to move right arm.”)
• Keep videos short but clear.

 

Requesting and Reviewing Medical Records

Obtaining your child’s medical records is your legal right. You should request:

• Complete delivery room notes
• Apgar score records
• Nurse and OB/GYN annotations
• Electronic Medical Record (EMR) entries
• Discharge summaries

Review these documents for inconsistencies. For example, if your baby had visible bruising, but the summary says “no complications,” note that. These discrepancies may become important later in court or during negotiations.

 

Organizing Your Documentation for Legal Review

When preparing for a possible claim, organization is everything. Create a system that includes:

• A folder for photos and videos (with file names including dates)
• A printed or digital journal with dated entries
• A copy of all hospital and pediatrician records
• A timeline summary outlining when each symptom appeared

Label and back up all files. Consider using a spreadsheet or document that outlines major events in chronological order.

 

Filing a Birth Injury Claim: What Parents Need to Know

If your documentation reveals a likely case of medical negligence, your next step may be to file a birth injury claim. Here’s how that process generally works:

Step 1: Contact a Birth Injury Attorney

Reach out to an attorney who specializes in medical malpractice, particularly birth injury cases. They will review your documentation, request additional records, and determine if you have a valid claim.

Step 2: Legal Investigation

The attorney will investigate:

• Whether the medical team breached their duty of care
• Whether that breach directly caused your child’s injury
• The extent and cost of your baby’s damages (both current and future)

Step 3: Filing the Lawsuit

If your attorney confirms that there is a case, they may file a claim against the hospital, doctor, nurse, or delivery team. Most birth injury cases settle out of court, but some go to trial if an agreement can’t be reached.

 

Types of Compensation in a Birth Injury Lawsuit

Compensation from a birth injury lawsuit is meant to cover the financial and emotional burden placed on your family. Damages can include:

Economic Damages

• Medical expenses (hospital bills, future care, surgeries)
• Therapy and rehabilitation costs
• In-home nursing care or medical equipment
• Lost wages if a parent had to stop working

Non-Economic Damages

• Pain and suffering of the child
• Emotional distress experienced by parents
• Loss of quality of life

Future Expenses

If your child will require lifelong care, compensation can include projected costs for the next 10, 20, or 50 years — including education, mobility aids, and caregiver support.

 

Mistakes to Avoid When Documenting a Birth Injury

1. Delaying documentation. Start immediately. Time-sensitive evidence can disappear quickly.
2. Failing to track behavior. Write down what you notice daily — even if you’re unsure whether it matters.
3. Relying only on the hospital. Your personal records may show things that hospital staff ignored or misrepresented.
4. Not backing up digital evidence. Save everything in multiple places (cloud, USB drive, printed files).

 

Frequently Asked Questions

What if I didn’t notice the injury right away?
It’s never too late to start documenting. Begin as soon as you suspect something is wrong and collect as much as possible.

Are timestamped photos legally valid?
Yes. Courts and insurance companies often accept timestamped, original images as supporting evidence.

How much does it cost to file a birth injury lawsuit?
Most attorneys work on a contingency basis, meaning they only get paid if you win or settle the case.

How long do I have to file a claim?
This depends on your state’s statute of limitations — but acting quickly is always in your best interest.

 

Final Thoughts: Take Action to Protect Your Child’s Rights

If your instincts tell you something went wrong during delivery, trust them. Start collecting evidence now. Your baby may not be able to speak for themselves — but your notes, photos, and records can.

By acting early, you give your child the best chance at proper care and the justice they may deserve.

 

Contact The Law Office of Miller & Gaudio PC Today

Birth injury cases are complex. Don’t try to navigate it alone. A qualified attorney can help you understand your options, evaluate your documentation, and take the next steps toward justice.

Contact us today for a free consultation. There’s no risk — and potentially everything to gain for your child’s future.