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Birth Experience Feedback

Please complete the form to the best of your ability to help us improve the birthing options available to women & their partners.

Prenatal High Risk Factors
Delivery Observations (select all that apply) Required
Reason(s) for Cesarean (Select all that appl)
Reason(s) or Induction (Select all that apply)
Cervical RipeningTechniques
Describe Rupture of Membranes (Select all that apply) Required
Fetal Montoring Used for Early Labor (up to 5 cm) Required
Fetal Montoring Used for Active Labor (after 5 cm) Required
If wireless monitoring was requested (verbally or on a birt plan), was it provided?
If Pitocin was used to augment labor, select all answers tha apply.
Placenta Delivery Details
If baby was separated from parents during the Golde Hour, choose the applicable reasons for the separation below.
For what parts of the birthing person's labor and delivery experience was the doula physically present and providing support? Sele all that applyt
How well was doula welcomed and respected by nurses?
PoorFairGoodVery goodExcellent
How well was doula welcomed and respected by medical providers?
PoorFairGoodVery goodExcellent
Describe the birthing person's ability to exercise informed consent during the birthing process. Select all answers that apply. Required

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