The record should match what you experienced
How to get your notes, and what to do when they do not match.
The anesthesia society's statement addresses this directly under documentation. It acknowledges that a patient's perception of an event during surgery may not match the clinician's, and then states: "An expression of pain or discomfort by the patient is valid and warrants a discussion regarding next steps."
In practice, what a woman reported and what was written down often diverge. In one review of newborn records after cesarean, only 1 of 17 accidental cuts to the baby had been recorded in the mother's chart.
Three things worth doing:
- Ask for your records. Request the operative report and the anesthesia record before you leave the hospital, or afterward in writing. You are entitled to them.
- Read them. Check whether your report of pain appears, whether the type of uterine incision is stated, and whether events match your memory.
- Ask for an addendum if they do not. You cannot change a clinician's note, but you can request that your own account be added to the record. Put the request in writing and keep a copy.
Why botherBecause the record is what the next doctor reads, in the next pregnancy, years from now. If it says the anesthesia was adequate and it was not, that is the version that follows you.
Where this comes from:
307. Smith JF, Hernandez C, Wax JR. Fetal laceration injury at cesarean delivery. Obstet Gynecol. 1997;90(3):344-346.
358. American Society of Anesthesiologists, Committee on Obstetric Anesthesia. Statement on pain during cesarean delivery. Approved October 18, 2023.
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This page is educational. It supports the conversation with your own clinicians. It is not consent to any treatment, and it cannot assess you. If you are worried about a symptom now, see urgent warning signs.