DIRECTIVE: REFUSAL OF ACTIVE MANAGEMENT

I, __________________ (Patient), being of sound mind, issue this directive regarding the Third Stage of Labor at __________________.

1. DEMAND FOR GRAVITY PROTOCOL: I elect to utilize the JSC Gravity Protocol. I need to be reminded at 2 minutes postpartum to squat, which eliminates the risk of excess bleeding or postpartum hemorrhage. I will deliver the placenta in squatting to allow optimal use of gravity and my abdominal muscles to assist in the expulsion of the placenta. This method has demonstrated a 0% rate of hemorrhage (>500mL) in clinical studies [2].

2. REFUSAL OF CORD TRACTION: I explicitly REFUSE routine "Controlled Cord Traction" (pulling on the umbilical cord). At 3 minutes postpartum, I allow gentle, encouraging touching of the cord to assist in delivery of the placenta while squatting.

3. REFUSAL OF PROPHYLACTIC OXYTOCIN: I refuse the administration of synthetic oxytocin (Pitocin) before or after the delivery of the placenta.

4. LIABILITY NOTICE: Any deviation from this directive by medical staff that results in injury, uterine inversion, or hemorrhage will be considered a violation of my informed refusal.

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PROVIDER REFUSED TO SIGN

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Witness / Provider

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Mother's Signature

Date: _______________

Clinical References:
[1] Williams Obstetrics, 26th Edition (2022). Cunningham et al. McGraw Hill.
[2] Cohain, J. S. (2022). "Novel third stage protocol reduces postpartum hemorrhage at vaginal birth." European Journal of Obstetrics & Gynecology and Reproductive Biology.

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