Post Birth Assessment Birthing Person

Post Birth Survey – Birthing Person

Please complete this assessment after you give birth! There will be a separate survey for your partner. A copy of this completed assessment will be sent by email to your own email address (to save for your own records), to your EBB Instructor, and to the EBB administrative team (for program evaluation).

Name(Required)
Name of your Support Person
Address
Name of your EBB Instructor(Required)
CO-INSTRUCTOR: Name of your EBB Instructor
If your class has 2 instructors, list the second instructor’s name here. If you have only 1 instructor, leave it blank.
If your class has 2 instructors, list the second instructor’s email here. If you have only 1 instructor, leave it blank.

Interest in Participating in Research

The responses on this survey may potentially be used for research. If used for research, your answers will be de-identified. This means that we will remove your name and all identifying information.
Do you give us permission to use your de-identified answers for research purposes in the future?(Required)

Your Baby's Birth

Type of Birth
Was your labor medically induced?
Please select which pain medications you used
Was oxytocin (Pitocin) given to speed up your labor?
Did your provider break your water to speed up your labor?

Your Satisfaction and Comfort

On a scale of 1 to 10, how satisfied were you with this birth?
Which comfort measures did you use during your labor? Please select all that apply.
I felt in control of choosing techniques and procedures that were used during my labor and birth.
After taking the Evidence Based Birth® Childbirth Class, but before my baby was born, I expected the pain of labor and birth to be:
After my baby was born, I felt the pain of labor and birth was:

Your Thoughts About Your Birth Experience

Typing my name below will serve as my signature. I understand that my results will be sent by email to the Evidence Based Birth® administration team, my personal EBB Instructor, and my own email address.(Required)