A Program Offered by
Birthing With Hypnosis
156 Fifth Avenue at 20 Street, Suite 534 # 7
New York, NY 10010
Please call 1 800 414 6274 or (646) 519 1076
Fax (212) 362 5762

We appreciate your taking the time to answer these questions as honestly as possible and in as much detail as possible.

Name
Date Baby Was Born
A) Was the baby born on or about the due date? Yes No
Due Date (indicate mo/day/yr)
Was your health care provider receptive to HypnoBirthing? Yes No
Comments, if possible
B) Was the birthing center, or hospital you chose receptive to HypnoBirthing? Yes No
Comments, if possible
Section C)

The following questions pertain to a natural vaginal birth; please see section D below if you did not have a normal vaginal birth.
1) How long was your labor?
Can you describe how you felt about your labor and delivery using HypnoBirthing?
2) During your labor were you offered any pain medication? Yes No
If so what type?
3) Did you accept pain medication, if so what type?
4) Were you offered Pitocin? Yes No
If you accepted Pitocin, can you describe what effect it had on your labor, if any , particularly your ability to maintain control.
5) Was HypnoBirthing more helpful during some parts and not other parts of your birthing experience? Describe?
6) Did HypnoBirthing help you to have the kind of birthing experience you wanted? Explain how it did, and how it may not have?
7) Did you practice your Hypnobirthing by listening to the tapes, Yes No
if yes, please describe how often?
Check off the category that best describes your practice. At least once per day At least 4 times per week At lease 2 times per week
Hardly at all I practice by myself all of the time I practiced with my partner some of the time
8) During your pregnancy, did you practice the perennial massage? religiously only sometimes not as often as I had wished
9) Did you have an episiotomy? Yes No
Did you tear? Yes No
Describe
10) Please rate how confident you felt about having the kind of birthing experience you wished after you completed the HypnoBirthing classes? Very confident Moderately Confident Somewhat confident but better than before the classes.
11) Did you require any assistance in the delivery of the baby during the last stage, such as forceps, or suction? Yes No
12) Would you choose Hypnobirthing again? Yes No
If yes, why, if no, why not?
Section D)

Complications of Labor & Delivery
1) Was labor induced? Yes No
If yes, how?
2) If, Yes, what were the medical reasons given for the "induction"?
3) What was the length of your labor?
4)Were there any complications of birth? Yes No
If so, what were they?
5) Did you receive any pain medication? Yes No
If so what type?
6) If you had a cesarean section, what were the medical reasons given that necessitated the cesarean section?
7) In spite of complications listed above, was HypnoBirthing helpful to you? If so, describe how it helped.
If it was not helpful , why not?
General Comments:



   

HypnoBirthing is taught in Group & Individual sessions.
These Sessions may also be Insurance Reimbursable

Birthing With Hypnosis
156 Fifth Avenue at 20 Street, Suite 534 # 7
New York, NY 10010
Please call 1 800 414 6274 or (646) 519 1076
Fax (212) 362 5762

e-mail: hypnobirthingnyc@aol.com