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POST DELIVERY FEEDBACK FORM

 

STUDENT


BIRTH DETAILS


PRE-LABOUR
Yes No Not at all
Yes No Not at all


LABOUR & DELIVERY
Time:    Date    
Time:    Date   
* On its own * Was made to burst * Did it leak
Time:    Date   
Time:    Date   
Time:    Date   
* Positive  * Negative 
Time:    Date   
*Normal *Vacuum *Forceps *Ceasarean
Sweep & Stretch Artificial Breaking of Water bag by Doctor
Drip Vaginal Application of Gel or Tablet
Oral Tablet
Time:    Date   
  R1 R2 R3
Drip 1 2 3
Vaginal Application 1 2 3
Oral Tablet 2 2 3
None Other
Waist Level Chest Level Out
Concentration Not Pushing Pushing
All of Them None Of Them
  Initially (1) Later Stages (2)
Yes 1 2
Yes Somewhat 1 2
Not Really 2 2
Definitely No 2 2
Hip Squzee Pressing /Massaging lower back Back Stroking, V Shaped Hand Squeeze
Leg Message Light abdominal Strokes Palms on lower back and lower abdomenr
yes right throughout only in the beginning only in the later stage not at all Comment
At Birth 6 Hours Later 12 Hours Later Later Than That
Yes No
Yes No
At Birth On 2nd Night Otherwise
Month (WEEKS)     ULTRASOUND OTHER TESTS
1 (1-4) Yes
2 (4-8) Yes
3 (8-12) Yes
4 (12-16) Yes
5 (16-20) Yes
6 (20-24) Yes
7 (24-28) Yes
8 (28-32) Yes
9 (32-36) Yes
  (36-40) Yes
Yes No
If Yes Righ Through Repeatedly
From   Date Time
To   Date Time
Up to the birth   Date Time


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