Parents Birth Report Survey Welcome to our Parents Birth Report Survey Name How many weeks was your pregnancy at the time of this birth? (gestational age)Less than 37 weeks37 weeks to 37 weeks 6 days38 weeks to 38 weeks 6 days39 weeks to 39 weeks 6 days40 weeks to 40 weeks 6 days41 weeks to 41 weeks 6 days42 weeks or moreWas this a multiple birth (twins, triplets, etc.)?YesNoWhat was your baby's birth weight?Less than 5 lb. 8 oz. (2500 gm.)Between 5 lb. 9 oz. to 6 lb. 9 oz. (2501-3000 gm.)Between 6 lb. 10 oz. to 7 lb. 11 oz. (3001 to 3500 gm.)Between 7 lb. 12 oz. to 8 lb. 13 oz. (3501 to 4000 gm.)Between 8 lb. 14 oz. to 9 lb. 14 oz. (4001 to 4500 gm.)More than 9 lb. 14 oz. (4500 gm.)Where did this birth take place?HomeHospital or hospital-affiliated birth centerBirth Center (not part of a hospital)Other (please specify)Which birthing professional(s) attended your birth? Please select all that apply Midwife OB-Gyn Family or general practice doctor No professional, unattended birth Other medical professional (please specify)Was the care provider who attended your birthingThe person or one of the people who took the lead in your prenatal careSomeone you met briefly during your prenatal careSomeone you did not meet until the time of your birthNo birthing professional present at birthWho were your birthing companions, the ones who were there primarily for your support? Select all that apply Spouse or partner Doula/professional labor companion HypnoBirthing practitioner who is also doula HypnoBirthing practitioner (not a doula) Your other child(ren) Other family member(s) Friend(s) No birthing companions Other (please specify)Thinking about the time after surges became fairly regular, how long was your labor? (Not counting pre-labor warmups, practice labor or early labor.)Less than 4 hours4 to 7 3/4 hours8 to 11 3/4 hours12 to 17 3/4 hours18 to 23 3/4 hoursMore than 24 hoursHow did your labor start?Labor started spontaneously, with no effort on my part to get it startedLabor began as a result of my efforts to induce or start itLabor was induced by care provider, did not start spontaneouslyHere is a list of things that are sometimes done during labor. Please check all that apply to this birth. Two or more vaginal exams Pitocin/syntocin to strengthen or speed up labor Rupture of membranes by care provider Epidural anesthesia Injection or IV medication for pain or sleep Nitrous oxide (Entonox, "gas & air") TENS Sterile water/saline injection (in lower back) IV fluids Continuous external monitoring Internal or baby scalp monitor Vacuum/ventouse Forceps Episiotomy None of the aboveDid you feel pressure from a medical professional to have any of these procedures or interventions?YesNoWere any procedures or interventions done without your full understanding or permission?YesNoDid you experience any perineal damage or tearing as a result of this birth?No, I did not tearYes, minor tearing, with or without stitchesYes, moderate tearing, requiring stitchesYes, tearing into anus or rectum, requiring stitchesWas this a surgical (Cesarean) birth?Yes, it was Cesarean birthNo, it was a vaginal birthWhat was the main position you used as your baby was coming out?Lying on backLying on sidePropped up, semi-recliningSquatting or using a birth stoolStandingKneelingWas your baby born in water?YesNoPlease rate your comfort level during during early labor (up to 6 or 8 cm)Comfortable (may be intense sensation)Mostly comfortableUncomfortablePainfulExtremely painfulPlease rate your comfort level during during late laborComfortable (may be intense sensation)Mostly comfortableUncomfortablePainfulExtremely painfulPlease rate your comfort level during during the birthing phaseComfortable (may be intense sensation)Mostly comfortableUncomfortablePainfulExtremely painfulRate mother's comfort in first 48 hrs. after birthingExcellentGoodFairPoorVery PoorRate mother's sense of well-being in first 48 hrs. after birthingExcellentGoodFairPoorVery PoorRate health of mother in first 48 hrs. after birthingExcellentGoodFairPoorVery PoorRate health of baby in first 48 hrs. after birthingExcellentGoodFairPoorVery PoorHypnoBirthing helped me be more confident in my ability to birthStrongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagreeHypnoBirthing helped me to be able to communicate better with my care providerStrongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagreeHypnoBirthing helped me to have a better understanding of my birthing optionsStrongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagreeHypnoBirthing helped me have a more gentle birthStrongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagreeHypnoBirthing helped me to have a more comfortable birthStrongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagreeHypnoBirthing helped me to have a shorter laborStrongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagreeHypnoBirthing helped me to have a safer birthStrongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagreeHypnoBirthing helped me to make good decisions for birthingStrongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagreeHypnoBirthing helped me to be adequately prepared for labor and birthStrongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagreeDuring the first hour after birth, was your baby primarilyIn your armsIn your spouse/partner’s armsWith staff for routine newborn careWith staff for special carePlease pick the statement that best describes your baby's first breastfeedingBaby crawled to breast and latched on within the first hourBaby breastfed within the first hour, but did not crawl to breastBaby first breastfed more than one hour after birthDid not breastfeed at all (mother's choice)Did not breastfeed at all (medical or other circumstances)If your were to have another baby, would you use HypnoBirthing?Yes, I would definitely use HypnoBirthingI may or may not use HypnoBirthingNo, I would not use HypnoBirthingWill you recommend HypnoBirthing to others?Yes, I will recommend HypnoBirthingI may or may not recommend HypnoBirthingI will not recommend HypnoBirthing(Optional)If you had this birth opportunity again, what would you do differently?(Optional)Please list any suggestions for improving the HypnoBirthing course:Apart from meeting your new baby, what was the best thing about your experience of giving birth? We would appreciate knowing as much detail as you care to provide.May we contact you for additional information or for permission to use your comments for educational purposes?YesNoIf you agree to be contacted for permission to use your comments please list your email address below.Time is Up! Comments comments
