Birth experience survey
If no choices fully apply, please fill in your own answer.
* Required
How many babies with this birth?
(Singleton, twins, triplets?)
Singleton
Twins
Triplets
Quadruplets or more
Gestational age
How many weeks along were you when labor began, or was induced, or when you were sectioned with no labor.
< 35
36-37
38-40
41
42
43+
Did you have an IV?
Yes
No, I had a Heplock
I had a Heplock that was eventually connected to IV (DURING labor)
No
Other:
Did you eat or drink during labor?
I ate
I drank
no
I was told not to
Other:
What type of fetal monitoring was used?
Constant via belts connected to unit
occasional strips via belts connected to unit
Constant via telemetry
occasional strips via telemetry
Hand-held doppler
Internal monitoring
Fetoscope
none
Other:
Did you enter into labor on your own?
Yes
No, I was induced
No, I had a C-section with no labor.
If you were induced, what method was employed?
If no choices fully apply, please fill in your own answer
Pitocin only
Cervidil only
Cervidil then Pitocin
Cytotec
Amniotomy
Nipple stimulation
Unsure
Other:
Was your labor augmented?
Yes, with Pitocin
Yes with Cervidil
Yes, with Cytotec
No
Unsure
Other:
If you recieved augmentation with Pitocin, how far dialated were you?
<2 cm
3-4 cm
5-6 cm
7-8 cm
>8 cm
Unsure
Other:
If you recieved pitocin, how many hours had you been in labor before it was started?
Please include hours you labored at home,dialation upon admission, and then hours of labor without Pit
Did you request Pitocin or was it recommended/required?
Scale of pain before Pitocin?
1
2
3
4
5
6
7
8
9
10
I'm having contractions?
Kill me!
Scale of pain after Pitocin?
1
2
3
4
5
6
7
8
9
10
I'm having contractions?
Kill me!
Did you recieve an Epidural?
No
Yes
No but I recieved other chemical pain relief.
I don't know
Other:
How dialated were you when the epidural was placed?
Please enter an answer.
Unsure
Other:
Did you recieve the epidural before or after the Pitocin?
I did not recieve pitocin.
Before Pitocin.
After Pitocin
I asked for the Epidural at the same time that it was decided I needed Pitocin.
What methods of pain relief did you try before requesting/reciving an epidural?
Breathing
Meditation
hypnosis
shower/ tub
massage
birth ball
rocking or swaying
accupressure
dancing
I requested the epidural the moment I was admitted
other chemical relief
Other:
What other chemical pain relief did you use?
Stadol
Entonox
Demerol
Fentanyl
Nubain
none
Other:
Did you move about during labor?
No, I stayed in bed
Yes, I moved around in bed
Yes, I walked the halls for awhile and then got in bed
I used a birthball/dancing/swaying/ etc
I labored on hands and knees/ squatting (in bed or not)
Other:
Did you use::
birth stool/chair
birth ball
Doula
partner-supported positioning (during labor)
squat-bar
Other:
What positions(s) did you use for pushing?
Squatting
hands and knees
leaning (over the bed, or other object)
sitting
reclining
on back
on back in stirrups
Other:
Did you tear of have an episiotomy?
No.
Yes, I tore
Yes, I had an episiotomy
Yes, I had an episiotmoy and then tore
unsure
Other:
If you tore or had an episiotomy, how deep was it?
1st= skin only. 2nd = ski and muscle 3rd = to the anal sphincter 4th = through anal sphincter
1st degree, no stitches
2nd degree, no stitches
2nd degree, with stiches
3rd degree
4th degree
unsure
Other:
Were any of the following used:
ventouse/ vaccum extraction
forceps
I don't know
Other:
Did you experience any of the following:
fetal distress/ nonreassuring fetal heart tones
shoulder dystocia
low blood pressure (maternal)
fever (maternal)
Other:
Did you have a cesarean?
yes
no
What was the indication for the Cesarean section?
Fetal distress
Cord prolapse
placenta previa
breech
failure to progress
macrosomia ("the baby is too big")
Cephalo pelvic disproportion.
uterine rupture
previous cesarean
Maternal exaustion
Other:
If there was fetal distress and you recieved pitocin, was the pitocin immediately discontinued?
Yes.
Yes, but they started it again later.
Yes, but it took them awhile to turn it off.
No.
No, it was increased.
Other:
Did you, at any time, feel pressured to have a cesarean?
No, no one ever said anything.
No, but I wanted one.
It was brought up, but I didn't feel pressured.
Yes, it was mentioned during labor.
Yes, it was mentioned frequently during labor.
Yes, the doctor recommended it before labor.
Yes, the doctor recommended it early on in pregnancy.
Yes and I agreed immediately.
Yes, and I eventually agreed to get them to leave me alone.
How did you feel about labor?
(pain, length, progress)
How did you feel about your epidural?
If you had one. Please elaborate.
How did you feel about your tear/episiotomy?
If you had one. Please elaborate.
How did you feel about your cesarean?
if you had one. Pleae elaborate
How did you feel about the birth, in general?
How long was your labor?
Did your doctor speak to you about the risks, benefits and alternatives to any or all interventions used during your labor, and allow you to ask questions?
This includes the IV, ALL medications, forceps/ vaccum, cesarean, etc.
Was anything done to you that you didn't agree to or want? Did youmention to anyone that you didn't want what was being offered, performed or recommended?
This includes the IV, ALL medications, forceps/ vaccum, cesarean, etc.
Did anything occur during your labor that I didn't cover, or is there anything you would like to add?
Please speak up if so! More facts are always welcomed.
If you would like me to contact you for more information, please leave an email address.
How did you find our survey?
*
Mothering.com
Alpha Inventions
Google search
Wordpress search
recommended by friend
Other: