Loss
Answers marked with a * are required.
 
1. Who were you getting your prenatal care from?






      
 
 
 
2. What types of issues did you have during your pregnancy with your loss?




















      
 
 
 
3. Where did you deliver?



      

 
 
 
4. If you delivered in the hospital, what type of birth was it?

      

 
 
 
5. If you had a vaginal hospital birth, what happened?

















      
 
 
 
6. If you had a c-section, how did it happen?







      
 
 
 
7. What gestation was your baby?




















      

 
 
 
8. Who delivered your baby?






      

 
 
 
9. If your baby was born still, what reasons have you been given?





      

 
 
 
10. If your baby passed after birth, are any of these a contributing factor?








      
 
 
 
11. In what ways did you educate yourself on labor/childbirth??













      
 
 
 
Do you believe that had things been different, your baby would of lived?? If so, please explain.
 
 
 
 
 

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