SA Birth Classes Questionnaire
May we use your words/ first name for marketing purposes if we wish?
Yes
No
Please email me if you wish to use them.
First Name
Partner's Name
Baby's Birthdate
Weight, Length
Sex
Male
Female
Number of children prior to this birth
Doctor/ midwife present at the birth
Hospital/ Birth Center/ Home
Type of birth
Vaginal
Cesarean
Was this a normal, full-term, uncomplicated pregnancy?
Yes
No (Please explain.)
Was labor medically induced?
No
Yes (Why?)
Did your health care provider rupture your membranes?
No
Yes
How did you know that labor had begun?
If birth was by cesarean, when were you told that a cesarean would have to be done?
What was the reason given for the cesarean?
Prior to birth, what was your rating on the "Pain Medication Preference Scale" (p.108)?
How long did you labor at home?
What was the approximate length of labor? How long did you push?
How many hours were you in the hospital before birth?
What medications were given during labor?
What medications were given during pushing?
How did you feel about these medications?
Describe how you pushed.
Did you have an episiotomy or tear?
Were forceps or vacuum extractor used?
No
Yes
Who was with you during labor?
Who was with you during the birth?
Describe briefly the type of guidance you received from your doctor/ midwife, nursing staff, and birth partner.
What were the positive parts of your birth experience?
What were the negative parts of your birth experience?
Were you able to keep your baby with you immediately after birth?
Yes
No
Describe your feelings at that time.
Did you have rooming-in?
Yes
No
How are you feeding your baby?
breast
formula
If the baby is a boy, did you have him circumcised?
No
Yes
Now that you have had a chance to use your knowledge, do you think any areas should have been stressed in greater detail? Include comments on class,class content, and/or instructor.
If you could change any aspect of your birth experience, what would it be?
What advice or recommendations do you have for couples having their babies at this hospital or birth center?
Is there anything else you would like to share about your class(es) and/ or birth experience?
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