ChildbirthJoy Prenatal Series Follow Up Form

ChildbirthJoy Follow-up Form Birth Experience

Please note that all fields followed by an asterisk must be filled in.

First Name*

Last Name*

E-Mail Address*

Street Address*

City*

Prov / State*

Postal Code / Zip*

Home Phone (incl area code)*

Business Phone (incl area code)

Partner's Name*

Baby's Due Date*

Actual Date of Birth*

Time of birth*

Baby's Gender*

Your baby's name!*

Baby's weight at birth*

Apgar score at 1 minute

Apgar score at 5 mins

Baby's present age*

Planned place of birth*

Actual place of birth*

Primary Care Giver (planned)*

Primary Care Provider (at birth)

Length of Early Labour (surges 5+ min apart)*

Length of Active Labour (3 surges in every 10 min period)*

Length of pushing*

Min after birth to deliver placenta*

Complications:*

	None
	GBS+
	Prolonged rupture of membranes
	Postdates
	Posterior Presentation
	Other

If other, please provide details:

Medications used:*

	None
	Pitocin
	Demerol
	Nubain
	Epidural
	Nitrous
	Oxide
	Local freezing for sutures postpartum
	Other

If other, please provide details:

Interventions:*

	None
	Induction
	Augmentation (meds to incourage contractions once in labour)
	Vacuum Extraction
	Forceps
	Caesarian
	Other

If other, please provide details:

Emergencies:*

	None
	Fetal distress - mild
	Fetal distress - severe
	Excess bleeding postpartum
	Newborn resuscitation
	Other

If other, please provide details:

Did ChildbirthJoy Prenatal Hypnosis aid your sense of self-confidence in late pregnancy? Please explain.*

For the partner: Was your confidence about your ability to assist her during the birth increased / decreased as a result of the ChildbirthJoy Prenatal Hypnosis series? Please explain.*

Did you use hypnosis during your birth?*

On a scale of 0 - 10, with 0 being no sensation and 10 being the most pain you could imagine, what did you expect you might feel during the birth? Go straight to question A.

A) Prior to the ChildbirthJoy Prenatal Hypnosis series*

B) After the ChildbirthJoy Prenatal Hypnosis series*

On a scale of 0 - 10, what level of discomfort / pain did you feel during the birth? Go to question A.

A) In early labour*

B) In active labour*

C) In transition*

D) During pushing*

E) The actual birth*

F) The 24 hr period after birth*

Was ChildbirthJoy Prenatal Hypnosis helpful for pain relief? Please provide details.*

Please describe what you felt during the surges.*

How was the birthing experience for you?*

How was the birth experience for your partner?*

If you know; how was the birth for the midwife / physician / nurse / doula? Relate their comments, if any.

Was the labour induced? If yes, please provide some details.*

Was there any complications or interventions during the birth or postpartum? If yes, please provide some details.*

What was the general health of your baby at birth? Good / oxygen needed / resuscitation / other:*

How was the postpartum period for you?*

Is your baby for example, fussy or calm? Please provide comments.*

Are you experiencing difficulty with depression or mood swings?*

Are you breastfeeding or bottle feeding? Please provide details of your experience.*

If you are experiencing any problems postpartum; would you like me to contact you?

Please enter the word that you see below.