Parents Birth Report Survey - Simply Natural Therapies

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 weeks

37 weeks to 37 weeks 6 days

38 weeks to 38 weeks 6 days

39 weeks to 39 weeks 6 days

40 weeks to 40 weeks 6 days

41 weeks to 41 weeks 6 days

42 weeks or more

Was this a multiple birth (twins, triplets, etc.)?

Yes

What 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?

Home

Hospital or hospital-affiliated birth center

Birth 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 birthing

The person or one of the people who took the lead in your prenatal care

Someone you met briefly during your prenatal care

Someone you did not meet until the time of your birth

No birthing professional present at birth

Who 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 hours

4 to 7 3/4 hours

8 to 11 3/4 hours

12 to 17 3/4 hours

18 to 23 3/4 hours

More than 24 hours

How did your labor start?

Labor started spontaneously, with no effort on my part to get it started

Labor began as a result of my efforts to induce or start it

Labor was induced by care provider, did not start spontaneously

Here 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 above

Did you feel pressure from a medical professional to have any of these procedures or interventions?

Yes

Were any procedures or interventions done without your full understanding or permission?

Yes

Did you experience any perineal damage or tearing as a result of this birth?

No, I did not tear

Yes, minor tearing, with or without stitches

Yes, moderate tearing, requiring stitches

Yes, tearing into anus or rectum, requiring stitches

Was this a surgical (Cesarean) birth?

Yes, it was Cesarean birth

No, it was a vaginal birth

What was the main position you used as your baby was coming out?

Lying on back

Lying on side

Propped up, semi-reclining

Squatting or using a birth stool

Standing

Kneeling

Was your baby born in water?

Yes

Please rate your comfort level during during early labor (up to 6 or 8 cm)

Comfortable (may be intense sensation)Mostly comfortableUncomfortablePainfulExtremely painful

Please rate your comfort level during during late labor

Comfortable (may be intense sensation)Mostly comfortableUncomfortablePainfulExtremely painful

Please rate your comfort level during during the birthing phase

Comfortable (may be intense sensation)Mostly comfortableUncomfortablePainfulExtremely painful

Rate mother's comfort in first 48 hrs. after birthing

ExcellentGoodFairPoorVery Poor

Rate mother's sense of well-being in first 48 hrs. after birthing

ExcellentGoodFairPoorVery Poor

Rate health of mother in first 48 hrs. after birthing

ExcellentGoodFairPoorVery Poor

Rate health of baby in first 48 hrs. after birthing

ExcellentGoodFairPoorVery Poor

HypnoBirthing helped me be more confident in my ability to birth