Elective Caesarean Section Form Either fill out the form below, or download the form by clicking here and you can print it and fill it out offline. Birth Plan for Elective Lower Segment Caesarean Section Name:* NHI:* EDD:* DOB:* Caesarean My partner is to be present at all times during the procedure I would like the baby to be shown to me immediately after it’s born I would like skin-to-skin with the baby as soon as I can I would like my partner to have skin-to-skin I would like to breastfeed as soon as possible If needed, I am happy for hand expressing if colostrum is needed Placenta/Whenua I would like to view the placenta/whenua I would like to keep the placenta/whenua I have a special container/ipu whenua for the placenta/whenua I do not wish to keep the placenta/whenua Newborn Procedures I would like all newborn procedures delayed until breastfeeding and bonding have occurred I would like the newborn procedures performed in my presence I would like the newborn procedures performed straight away If the baby has any problems, I would like my partner to be with the baby at all times, if possible Vitamin K I do not want my baby to have Vitamin K I wish for my baby to have Vitamin K orally I wish for my baby to have IM injection of Vitamin K Immunisations I am aware that my baby requires Hep B Vaccination after birth, and a bath prior to vaccination I am aware that my baby requires Tuberculosis vaccination I will be vaccinating my baby I have chosen not to vaccinate my baby and will opt off the Immunisation Register Guthrie I am happy for routine metabolic testing I request the fourth test to be returned I have chosen to not do routine metabolic testing Breastfeeding My beliefs around breastfeeding discussed Breast and nipple anatomy discussed Partner and family support/beliefs discussed I have chosen to exclusively breastfeed my baby I would prefer to bottle-feed I would like to breast and bottle-feed I would like to avoid using a pacifier I would like a consultation with a Lactation Consultant Expressing indications discussed I would consider donor milk Length of Stay in the Birthing Unit or Hospital I would like to leave as soon as possible after the delivery of baby I would like to stay in the hospital for days if possible Submit
