EmailMe Form - Previous Birth Experience

Your Name *

Your Email

Your Partner's Name *

Hospital you delivered the last baby at

The care provider who delivered your last baby

What was your due date last time?

MM / DD / YYYY

When did you actually deliver?

MM / DD / YYYY

Child's Name

Child's Age

Weight at birth

Did your labor start on its own?

Yes

No

If no, how was labor induced? At how many weeks gestation? What was the reason?

How did your water break

On it's own (SROM)

With assistance (AROM)

Not sure

Was your labor augmented (helped along in any way?) If yes, please tell me how.

Was Pitocin used?

Yes

No

I don't know

If yes, please tell me about it. When was it used, do you know how much. Did you have an epidural?

Did you use any pain medications? If yes, please list them.

If yes to the above, please tell me about your experience with it. Did it work for you? What did you think of it? Do you plan on using it again?

Did you have...

If you had a cesarean birth, what was the reason you were given as to why?

Any complications in your postpartum healing?

Who supported you during this labor?

What helped you the most during the labor and delivery?

What surprised you the most during the labor and delivery?

Is there anything you would like to do differently this time?

Is there anything you want to do the same?

Did you breastfeed?

Yes

No

For how long?

Did you have any difficulty breastfeeding? Please explain if you did.

Is there anything else about your previous birth you would like to me know about, anything that might be helpful for me to know?