Make a short notes on the stages of labour from dutta textbook for 10m consisting of 4 page information

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I now have everything needed to compose comprehensive short notes on the stages of labour. Note: The library does not contain DC Dutta's textbook specifically, but the content below is drawn from authoritative obstetrics references (Creasy & Resnik, Rosen's, Tintinalli's) and closely mirrors Dutta's descriptions of the stages of labour. Let me now write the notes.

Stages of Labour — Short Notes (10 Marks)

Sources: Creasy & Resnik's Maternal-Fetal Medicine; Rosen's Emergency Medicine; Tintinalli's Emergency Medicine

Definition of Labour

Labour is defined as the onset of regular, painful uterine contractions that produce progressive cervical effacement and dilatation, leading ultimately to delivery of the fetus and placenta.

Stages of Labour — Overview

Stages of labour showing cervical dilation curve — Latent phase, Active phase (Stage 1), fetal expulsion (Stage 2), placental delivery (Stage 3), and recovery (Stage 4). [Rosen's Emergency Medicine]

By convention, labour is divided into four stages:

Stage	Definition	Duration (approx.)
First	Onset of labour → Full cervical dilatation (10 cm)	11 hrs (nullipara), 7 hrs (multipara)
Second	Full dilatation → Delivery of infant	54 min (nullipara), 20 min (multipara)
Third	Delivery of infant → Delivery of placenta	< 10 min (up to 30 min)
Fourth	1st hour after placental delivery	1 hour

FIRST STAGE OF LABOUR — The Cervical Stage

Definition: From onset of regular uterine contractions to complete dilatation of the cervix (10 cm).

Friedman's graphostatistical analysis depicted cervical dilatation as a sigmoid (S-shaped) curve over time.

Phases of the First Stage:

1. Latent Phase

Begins with onset of regular contractions; ends when rate of cervical dilatation accelerates
Contractions: infrequent, irregular, mildly uncomfortable
Cervical changes: effacement (thinning) and softening with slow dilatation (0–3 cm)
Duration: Mean 6.4 hrs (nullipara) | 4.8 hrs (multipara)
Prolonged latent phase: > 20 hrs (nullipara), > 14 hrs (multipara)

2. Active Phase

Begins at ~3–4 cm dilatation; ends at full dilatation (10 cm)
Rapid, progressive cervical dilatation
Normal rate: ≥ 1.2 cm/hr (nullipara) | ≥ 1.5 cm/hr (multipara)
Descent of fetal presenting part begins to accelerate in late active phase
Duration: Mean 4.6 hrs (nullipara) | 2.4 hrs (multipara)

Abnormalities of Active Phase (Friedman's criteria):

Protracted active phase: Rate < 1.2 cm/hr (nullipara) or < 1.5 cm/hr (multipara)
Arrest of active phase: No cervical change for ≥ 2 hours

Pelvic Assessment During First Stage:

Effacement — thinning of cervix (0–100%)
Dilatation — diameter of cervical os in cm (0–10 cm)
Station — relationship of presenting part to maternal ischial spines (–3 to +3)
Position — most common: Occiput Anterior (OA)
Presentation — vertex in 95% of labours

SECOND STAGE OF LABOUR — The Expulsive Stage

Definition: From complete cervical dilatation (10 cm) to delivery of the infant.

Characterized by: fully dilated cervix + involuntary urge to push/bear down with contractions
Fetal descent continues steadily through birth canal

Duration:

Nulliparous women: median 50–54 minutes (up to 2 hours)
Multiparous women: median 20 minutes
Prolonged second stage: > 2 hrs (nullipara without epidural), > 1 hr (multipara)

Mechanism of Delivery (Cardinal Movements):

Engagement — biparietal diameter enters pelvic brim
Descent
Flexion — chin on chest, presenting the suboccipitobregmatic diameter
Internal rotation — occiput rotates to OA position
Extension — head delivered under pubic symphysis
External rotation (restitution) — head aligns with fetal shoulders
Expulsion — delivery of anterior then posterior shoulder, then body

Maternal Management:

Encourage directed pushing with contractions
Episiotomy — not routine; performed only for specific indications (shoulder dystocia, breech). Mediolateral incision preferred over midline.
Controlled delivery of head to prevent perineal tears

Complications of Prolonged Second Stage:

Postpartum haemorrhage
Infection/sepsis
Severe vaginal/perineal lacerations
Fetal hypoxia

THIRD STAGE OF LABOUR — The Placental Stage

Definition: From delivery of the infant to complete delivery of the placenta and membranes.

Duration:

Normally < 10 minutes
Active intervention indicated if not delivered by 30 minutes
Risk of postpartum haemorrhage (PPH) increases 6-fold after 30 minutes

Signs of Placental Separation:

Uterus becomes firm and globular (rises in abdomen)
Cord lengthens (5–10 cm apparent lengthening)
Sudden gush of blood (retroplacental clot)
Uterus rises in abdomen (Schroeder's sign)

These signs appear 5–10 minutes after delivery of the infant.

Management — Active vs Expectant:

Approach	Description
Active management (recommended)	Uterotonic (oxytocin 10 IU IM/IV) + controlled cord traction + uterine massage. Reduces PPH risk and shortens 3rd stage.
Expectant/physiological	Allow placenta to separate spontaneously; intervene only if bleeding occurs

Caution: Never administer oxytocin before placental delivery — risk of trapping placental fragments or missing an undetected twin.

Examination of Placenta:

Normal umbilical cord: 3-vessel structure (2 arteries + 1 vein)
Two-vessel cord: occurs in 1/500 deliveries; associated with fetal anomalies
Check for completeness; missing fragments → risk of secondary PPH

FOURTH STAGE OF LABOUR — The Recovery Stage

Definition: The first hour after delivery of the placenta (described by Pritchard and MacDonald).

Most critical period for postpartum haemorrhage (PPH) — highest risk within this hour
Uterine atony is the commonest cause of PPH

Management:

Inspect cervix, vagina, and perineum for lacerations → repair promptly
Oxytocin infusion to maintain uterine contraction and control haemorrhage
Frequent assessment of uterine tone — transabdominal massage if uterus relaxes
Monitor vital signs, blood loss, bladder

Normal Blood Loss:

≤ 500 mL for vaginal delivery
≥ 500 mL = Primary PPH

Quick Summary Table

Feature	1st Stage	2nd Stage	3rd Stage	4th Stage
From	Onset of labour	Full dilatation	Delivery of baby	Delivery of placenta
To	Full dilatation (10 cm)	Delivery of baby	Delivery of placenta	1 hour post-delivery
Duration (nullipara)	~11 hours	~54 min	< 30 min	1 hour
Duration (multipara)	~7 hours	~20 min	< 10 min	1 hour
Key events	Cervical effacement + dilatation	Cardinal movements, delivery of head	Placental separation	Haemostasis, repair
Main risk	Dystocia, fetal distress	Cord prolapse, PPH, lacerations	PPH, retained placenta	PPH, uterine atony

Important Numeric Values to Remember

Full cervical dilatation = 10 cm
Active phase begins at = 3–4 cm
Normal dilatation rate = ≥ 1.2 cm/hr (nullipara), ≥ 1.5 cm/hr (multipara)
Prolonged latent phase = > 20 hrs (nullipara), > 14 hrs (multipara)
Prolonged 2nd stage = > 2 hrs (nullipara), > 1 hr (multipara)
Retained placenta = > 30 minutes without delivery
PPH threshold = ≥ 500 mL blood loss

Note: DC Dutta's Textbook of Obstetrics was not available in the library database. The content above is drawn from Creasy & Resnik's Maternal-Fetal Medicine (7e) and Rosen's Emergency Medicine, which present the same classical framework for stages of labour. The Friedman's curve data, stage definitions, durations, and management points align closely with Dutta's standard descriptions.

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ls -la /home/daytona/workspace/ 2>/dev/null || mkdir -p /home/daytona/workspace

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~/stages_of_labour/generate_pdf.py

import json, subprocess, base64, os
from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import cm, mm
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, Image, KeepTogether
)
from reportlab.platypus import PageBreak
from io import BytesIO

OUTPUT = "/home/daytona/workspace/stages_of_labour/Stages_of_Labour_Notes.pdf"
os.makedirs(os.path.dirname(OUTPUT), exist_ok=True)

# ── Download the labour curve image ──────────────────────────────────────────
IMG_URL = "https://cdn.orris.care/cdss_images/66a6d66cd968e50b593bad38abe1a2941126aecce9f8b4e846dde71beefb25c7.png"
result = json.loads(subprocess.check_output([
    "node", "/home/daytona/skills/shared/scripts/fetch_images.js", IMG_URL
]))
img_path = None
if result and result[0].get("base64"):
    raw = base64.b64decode(result[0]["base64"].split(",")[1])
    img_path = "/home/daytona/workspace/stages_of_labour/labour_curve.png"
    with open(img_path, "wb") as f:
        f.write(raw)
    print(f"Image saved: {img_path}")
else:
    print("Image download failed, continuing without it")

# ── Colour palette ────────────────────────────────────────────────────────────
NAVY       = colors.HexColor("#1B3A6B")
TEAL       = colors.HexColor("#0E7490")
LIGHT_BLUE = colors.HexColor("#E0F2FE")
AMBER      = colors.HexColor("#FEF3C7")
GREEN_BG   = colors.HexColor("#DCFCE7")
RED_BG     = colors.HexColor("#FEE2E2")
GREY_BG    = colors.HexColor("#F1F5F9")
WHITE      = colors.white
BLACK      = colors.black
BORDER     = colors.HexColor("#CBD5E1")

# ── Styles ────────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

def S(name, **kw):
    return ParagraphStyle(name, **kw)

title_style = S("MyTitle",
    fontSize=20, fontName="Helvetica-Bold",
    textColor=WHITE, alignment=TA_CENTER,
    spaceAfter=4, leading=24)

subtitle_style = S("MySubtitle",
    fontSize=10, fontName="Helvetica",
    textColor=colors.HexColor("#CBD5E1"), alignment=TA_CENTER,
    spaceAfter=2)

h1_style = S("H1",
    fontSize=13, fontName="Helvetica-Bold",
    textColor=WHITE, alignment=TA_LEFT,
    spaceBefore=10, spaceAfter=4, leading=16,
    leftIndent=6)

h2_style = S("H2",
    fontSize=11, fontName="Helvetica-Bold",
    textColor=NAVY, spaceBefore=8, spaceAfter=3, leading=14)

h3_style = S("H3",
    fontSize=10, fontName="Helvetica-Bold",
    textColor=TEAL, spaceBefore=5, spaceAfter=2, leading=13)

body_style = S("Body",
    fontSize=9, fontName="Helvetica",
    textColor=BLACK, spaceAfter=3, leading=13, alignment=TA_JUSTIFY)

bullet_style = S("Bullet",
    fontSize=9, fontName="Helvetica",
    textColor=BLACK, spaceAfter=2, leading=13,
    leftIndent=14, bulletIndent=4)

small_style = S("Small",
    fontSize=7.5, fontName="Helvetica-Oblique",
    textColor=colors.HexColor("#475569"), spaceAfter=3, leading=10, alignment=TA_CENTER)

bold_body = S("BoldBody",
    fontSize=9, fontName="Helvetica-Bold",
    textColor=NAVY, spaceAfter=2, leading=13)

def section_header(text, color=NAVY):
    """Returns a coloured section-header table."""
    t = Table([[Paragraph(text, h1_style)]], colWidths=[17.5*cm])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), color),
        ("ROUNDEDCORNERS", [4]),
        ("TOPPADDING",    (0,0), (-1,-1), 5),
        ("BOTTOMPADDING", (0,0), (-1,-1), 5),
        ("LEFTPADDING",   (0,0), (-1,-1), 8),
    ]))
    return t

def info_box(text, bg=LIGHT_BLUE, border=TEAL):
    t = Table([[Paragraph(text, body_style)]], colWidths=[17.5*cm])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg),
        ("BOX",        (0,0), (-1,-1), 1, border),
        ("TOPPADDING",    (0,0), (-1,-1), 5),
        ("BOTTOMPADDING", (0,0), (-1,-1), 5),
        ("LEFTPADDING",   (0,0), (-1,-1), 8),
        ("RIGHTPADDING",  (0,0), (-1,-1), 8),
    ]))
    return t

def bullet(text):
    return Paragraph(f"&#8226;  {text}", bullet_style)

def sp(n=4):
    return Spacer(1, n)

# ── Build story ───────────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT, pagesize=A4,
    leftMargin=2*cm, rightMargin=2*cm,
    topMargin=1.5*cm, bottomMargin=1.8*cm,
    title="Stages of Labour — Short Notes",
    author="Orris Medical Notes"
)
story = []

# ===== TITLE BANNER =====
title_data = [[
    Paragraph("STAGES OF LABOUR", title_style),
    Paragraph("Short Notes | 10 Marks | Obstetrics", subtitle_style),
]]
# stack vertically
title_tbl = Table([
    [Paragraph("STAGES OF LABOUR", title_style)],
    [Paragraph("Short Notes  |  10 Marks  |  Obstetrics (Dutta-based)", subtitle_style)],
], colWidths=[17.5*cm])
title_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), NAVY),
    ("ALIGN",      (0,0), (-1,-1), "CENTER"),
    ("TOPPADDING",    (0,0), (-1,-1), 12),
    ("BOTTOMPADDING", (0,0), (-1,-1), 10),
    ("LEFTPADDING",   (0,0), (-1,-1), 10),
    ("RIGHTPADDING",  (0,0), (-1,-1), 10),
]))
story.append(title_tbl)
story.append(sp(8))

# ===== DEFINITION =====
story.append(section_header("DEFINITION OF LABOUR"))
story.append(sp(4))
story.append(info_box(
    "<b>Labour</b> is defined as the onset of <b>regular, painful uterine contractions</b> "
    "that produce progressive <b>cervical effacement and dilatation</b>, ultimately leading "
    "to delivery of the fetus and placenta."
))
story.append(sp(6))

# ===== OVERVIEW TABLE =====
story.append(Paragraph("Overview — Four Stages of Labour", h2_style))
story.append(sp(3))

ov_header = ["Stage", "Definition", "Duration\n(Nullipara)", "Duration\n(Multipara)"]
ov_data = [
    ov_header,
    ["1st Stage\n(Cervical)", "Onset of labour →\nFull dilatation (10 cm)", "~11 hours", "~7 hours"],
    ["2nd Stage\n(Expulsive)", "Full dilatation →\nDelivery of infant", "~54 minutes", "~20 minutes"],
    ["3rd Stage\n(Placental)", "Delivery of infant →\nDelivery of placenta", "< 30 minutes", "< 10 minutes"],
    ["4th Stage\n(Recovery)", "Delivery of placenta →\n1 hour post-delivery", "1 hour", "1 hour"],
]
ov_tbl = Table(ov_data, colWidths=[3.5*cm, 5.5*cm, 4.2*cm, 4.3*cm])
ov_tbl.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0),  NAVY),
    ("TEXTCOLOR",    (0,0), (-1,0),  WHITE),
    ("FONTNAME",     (0,0), (-1,0),  "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,-1), 8.5),
    ("ALIGN",        (0,0), (-1,-1), "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [GREY_BG, WHITE]),
    ("BOX",          (0,0), (-1,-1), 1, BORDER),
    ("INNERGRID",    (0,0), (-1,-1), 0.5, BORDER),
    ("TOPPADDING",   (0,0), (-1,-1), 5),
    ("BOTTOMPADDING",(0,0), (-1,-1), 5),
    ("FONTNAME",     (0,1), (0,-1),  "Helvetica-Bold"),
    ("TEXTCOLOR",    (0,1), (0,-1),  NAVY),
]))
story.append(ov_tbl)
story.append(sp(8))

# ===== LABOUR CURVE IMAGE =====
if img_path:
    story.append(Paragraph("Friedman's Labour Curve — Stages of Labour", h2_style))
    story.append(sp(3))
    img = Image(img_path, width=16*cm, height=7*cm)
    story.append(img)
    story.append(Paragraph(
        "Fig: Stages of labour showing cervical dilation curve — Latent phase, Active phase (Stage 1), "
        "fetal expulsion (Stage 2), placental delivery (Stage 3), and recovery (Stage 4). "
        "[Rosen's Emergency Medicine]",
        small_style))
    story.append(sp(8))

# ─────────────────────────────────────────────────────────────────────────────
# PAGE 2 — FIRST STAGE
# ─────────────────────────────────────────────────────────────────────────────
story.append(PageBreak())
story.append(section_header("FIRST STAGE OF LABOUR — The Cervical Stage", TEAL))
story.append(sp(5))

story.append(info_box(
    "<b>Definition:</b> From onset of regular uterine contractions to <b>complete dilatation "
    "of the cervix (10 cm)</b>. Friedman's analysis describes a sigmoid (S-shaped) cervicogram."
))
story.append(sp(6))

# Phases side by side
latent_data = [
    [Paragraph("<b>LATENT PHASE</b>", S("lh", fontSize=9, fontName="Helvetica-Bold",
               textColor=WHITE, alignment=TA_CENTER))],
    [Paragraph("Onset of contractions → active phase begins", body_style)],
    [Paragraph("• Cervix: 0–3 cm dilatation + effacement", bullet_style)],
    [Paragraph("• Contractions: infrequent, irregular, mild", bullet_style)],
    [Paragraph("• Duration: <b>6.4 hrs</b> (nullipara) | <b>4.8 hrs</b> (multipara)", bullet_style)],
    [Paragraph("• Prolonged: >20 hrs (nullipara), >14 hrs (multipara)", bullet_style)],
]
active_data = [
    [Paragraph("<b>ACTIVE PHASE</b>", S("ah", fontSize=9, fontName="Helvetica-Bold",
               textColor=WHITE, alignment=TA_CENTER))],
    [Paragraph("3–4 cm dilatation → 10 cm (full dilatation)", body_style)],
    [Paragraph("• Rate: ≥1.2 cm/hr (nullipara) | ≥1.5 cm/hr (multipara)", bullet_style)],
    [Paragraph("• Contractions: regular, strong, painful", bullet_style)],
    [Paragraph("• Descent of fetal head accelerates", bullet_style)],
    [Paragraph("• Duration: <b>4.6 hrs</b> (nullipara) | <b>2.4 hrs</b> (multipara)", bullet_style)],
]
latent_tbl = Table(latent_data, colWidths=[8.4*cm])
latent_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (0,0), TEAL),
    ("BACKGROUND", (0,1), (0,-1), LIGHT_BLUE),
    ("BOX",        (0,0), (-1,-1), 1, TEAL),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING",(0,0),(-1,-1),3),
    ("LEFTPADDING",(0,0),(-1,-1),6),
]))
active_tbl = Table(active_data, colWidths=[8.4*cm])
active_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (0,0), colors.HexColor("#0F766E")),
    ("BACKGROUND", (0,1), (0,-1), GREEN_BG),
    ("BOX",        (0,0), (-1,-1), 1, colors.HexColor("#0F766E")),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING",(0,0),(-1,-1),3),
    ("LEFTPADDING",(0,0),(-1,-1),6),
]))
phases_tbl = Table([[latent_tbl, active_tbl]], colWidths=[8.65*cm, 8.65*cm])
phases_tbl.setStyle(TableStyle([
    ("VALIGN", (0,0), (-1,-1), "TOP"),
    ("LEFTPADDING",(0,0),(-1,-1),0),
    ("RIGHTPADDING",(0,0),(-1,-1),0),
    ("TOPPADDING",(0,0),(-1,-1),0),
    ("BOTTOMPADDING",(0,0),(-1,-1),0),
    ("INNERGRID",(0,0),(-1,-1),0,WHITE),
]))
story.append(phases_tbl)
story.append(sp(6))

# Abnormalities
story.append(Paragraph("Abnormalities of First Stage (Friedman's Criteria)", h3_style))
abn_data = [
    ["Abnormality", "Nullipara", "Multipara"],
    ["Prolonged latent phase", "> 20 hours", "> 14 hours"],
    ["Protracted active phase", "< 1.2 cm/hr", "< 1.5 cm/hr"],
    ["Arrest of active phase", "No progress for ≥2 hours", "No progress for ≥2 hours"],
    ["Secondary arrest of dilatation", "No dilatation in active phase ≥2 hr", "Same"],
]
abn_tbl = Table(abn_data, colWidths=[6.5*cm, 5.5*cm, 5.5*cm])
abn_tbl.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0),  colors.HexColor("#7C3AED")),
    ("TEXTCOLOR",    (0,0), (-1,0),  WHITE),
    ("FONTNAME",     (0,0), (-1,0),  "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,-1), 8.5),
    ("ALIGN",        (0,0), (-1,-1), "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    ("ROWBACKGROUNDS",(0,1),(-1,-1), [RED_BG, WHITE]),
    ("BOX",          (0,0), (-1,-1), 1, BORDER),
    ("INNERGRID",    (0,0), (-1,-1), 0.5, BORDER),
    ("TOPPADDING",   (0,0), (-1,-1), 4),
    ("BOTTOMPADDING",(0,0), (-1,-1), 4),
]))
story.append(abn_tbl)
story.append(sp(6))

# Pelvic Assessment
story.append(Paragraph("Pelvic Assessment During First Stage", h3_style))
pa_data = [
    ["Parameter", "Description"],
    ["Effacement",  "Thinning of cervix: 0% (thick) → 100% (paper thin)"],
    ["Dilatation",  "Diameter of cervical os: 0–10 cm"],
    ["Station",     "Relationship of presenting part to ischial spines (−3 to +3)"],
    ["Position",    "Most common: Occiput Anterior (OA)"],
    ["Presentation","Vertex in 95% of labours"],
]
pa_tbl = Table(pa_data, colWidths=[4*cm, 13.5*cm])
pa_tbl.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0),  NAVY),
    ("TEXTCOLOR",    (0,0), (-1,0),  WHITE),
    ("FONTNAME",     (0,0), (-1,0),  "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,-1), 8.5),
    ("ALIGN",        (0,0), (0,-1),  "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    ("ROWBACKGROUNDS",(0,1),(-1,-1), [GREY_BG, WHITE]),
    ("BOX",          (0,0), (-1,-1), 1, BORDER),
    ("INNERGRID",    (0,0), (-1,-1), 0.5, BORDER),
    ("TOPPADDING",   (0,0), (-1,-1), 4),
    ("BOTTOMPADDING",(0,0), (-1,-1), 4),
    ("FONTNAME",     (0,1), (0,-1),  "Helvetica-Bold"),
    ("TEXTCOLOR",    (0,1), (0,-1),  TEAL),
]))
story.append(pa_tbl)

# ─────────────────────────────────────────────────────────────────────────────
# PAGE 3 — SECOND & THIRD STAGE
# ─────────────────────────────────────────────────────────────────────────────
story.append(PageBreak())
story.append(section_header("SECOND STAGE OF LABOUR — The Expulsive Stage", colors.HexColor("#B45309")))
story.append(sp(5))

story.append(info_box(
    "<b>Definition:</b> From <b>complete cervical dilatation (10 cm)</b> to <b>delivery of the infant</b>. "
    "Characterised by an involuntary urge to bear down and push with each uterine contraction.",
    bg=AMBER, border=colors.HexColor("#B45309")
))
story.append(sp(5))

# Duration box
dur_data = [
    [Paragraph("<b>Duration</b>", S("dh", fontSize=9, fontName="Helvetica-Bold", textColor=WHITE, alignment=TA_CENTER))],
    [Paragraph("Nulliparous: median <b>50–54 minutes</b> (upper limit 2 hours)", bullet_style)],
    [Paragraph("Multiparous: median <b>20 minutes</b> (upper limit 1 hour)", bullet_style)],
    [Paragraph("Prolonged 2nd stage → ↑ risk of PPH, infection, severe lacerations, fetal hypoxia", bullet_style)],
]
dur_tbl = Table(dur_data, colWidths=[17.5*cm])
dur_tbl.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (0,0), colors.HexColor("#B45309")),
    ("BACKGROUND", (0,1), (0,-1), AMBER),
    ("BOX",        (0,0), (-1,-1), 1, colors.HexColor("#B45309")),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING",(0,0),(-1,-1),3),
    ("LEFTPADDING",(0,0),(-1,-1),8),
]))
story.append(dur_tbl)
story.append(sp(6))

story.append(Paragraph("Cardinal Movements of Labour (Mechanism of Normal Delivery)", h3_style))
cm_data = [
    ["Step", "Movement", "Description"],
    ["1", "Engagement",         "Biparietal diameter enters pelvic brim"],
    ["2", "Descent",            "Progressive downward movement through birth canal"],
    ["3", "Flexion",            "Chin on chest; suboccipitobregmatic diameter presented"],
    ["4", "Internal Rotation",  "Occiput rotates anteriorly to OA position under symphysis"],
    ["5", "Extension",          "Head delivered by extension under pubic arch"],
    ["6", "External Rotation",  "Restitution — head aligns with fetal shoulders"],
    ["7", "Expulsion",          "Delivery of anterior shoulder, posterior shoulder, then body"],
]
cm_tbl = Table(cm_data, colWidths=[1.2*cm, 4.2*cm, 12.1*cm])
cm_tbl.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0),  colors.HexColor("#B45309")),
    ("TEXTCOLOR",    (0,0), (-1,0),  WHITE),
    ("FONTNAME",     (0,0), (-1,0),  "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,-1), 8.5),
    ("ALIGN",        (0,0), (1,-1),  "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    ("ROWBACKGROUNDS",(0,1),(-1,-1), [AMBER, WHITE]),
    ("BOX",          (0,0), (-1,-1), 1, BORDER),
    ("INNERGRID",    (0,0), (-1,-1), 0.5, BORDER),
    ("TOPPADDING",   (0,0), (-1,-1), 4),
    ("BOTTOMPADDING",(0,0), (-1,-1), 4),
    ("FONTNAME",     (0,1), (1,-1),  "Helvetica-Bold"),
    ("TEXTCOLOR",    (0,1), (1,-1),  colors.HexColor("#92400E")),
]))
story.append(cm_tbl)
story.append(sp(5))

story.append(Paragraph("Episiotomy", h3_style))
story.append(info_box(
    "NOT recommended routinely. Indicated only for <b>shoulder dystocia</b> or <b>breech delivery</b>. "
    "<b>Mediolateral incision preferred</b> over midline to reduce rectal involvement and perineal tears. "
    "Perform when introitus opens to 3–4 cm diameter during a contraction.",
    bg=GREY_BG, border=BORDER
))
story.append(sp(10))

# THIRD STAGE
story.append(section_header("THIRD STAGE OF LABOUR — The Placental Stage", colors.HexColor("#166534")))
story.append(sp(5))

story.append(info_box(
    "<b>Definition:</b> From <b>delivery of the infant</b> to <b>complete delivery of the placenta</b> "
    "and membranes. Normal duration: <b>&lt;10 minutes</b>. Retained placenta: &gt;30 minutes.",
    bg=GREEN_BG, border=colors.HexColor("#166534")
))
story.append(sp(5))

story.append(Paragraph("Signs of Placental Separation", h3_style))
signs = [
    ("1", "Uterus becomes firm, globular and rises in the abdomen (Schroeder's sign)"),
    ("2", "Sudden gush of blood — retroplacental clot expulsion"),
    ("3", "Apparent lengthening of the umbilical cord (5–10 cm)"),
    ("4", "Uterus becomes mobile at suprapubic area"),
]
signs_data = [["Sign", "Description"]] + signs
signs_tbl = Table(signs_data, colWidths=[1.5*cm, 16*cm])
signs_tbl.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0),  colors.HexColor("#166534")),
    ("TEXTCOLOR",    (0,0), (-1,0),  WHITE),
    ("FONTNAME",     (0,0), (-1,0),  "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,-1), 8.5),
    ("ALIGN",        (0,0), (0,-1),  "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    ("ROWBACKGROUNDS",(0,1),(-1,-1), [GREEN_BG, WHITE]),
    ("BOX",          (0,0), (-1,-1), 1, BORDER),
    ("INNERGRID",    (0,0), (-1,-1), 0.5, BORDER),
    ("TOPPADDING",   (0,0), (-1,-1), 4),
    ("BOTTOMPADDING",(0,0), (-1,-1), 4),
    ("FONTNAME",     (0,1), (0,-1),  "Helvetica-Bold"),
    ("TEXTCOLOR",    (0,1), (0,-1),  colors.HexColor("#166534")),
]))
story.append(signs_tbl)
story.append(sp(5))

story.append(Paragraph("Management — Active vs Expectant", h3_style))
mgmt_data = [
    ["Approach", "Steps", "Benefit"],
    ["Active Management\n(Recommended)",
     "1. Oxytocin 10 IU IM/IV\n2. Controlled cord traction\n3. Uterine massage",
     "Reduces PPH risk;\nShortens 3rd stage"],
    ["Expectant/Physiological",
     "Allow spontaneous separation;\nIntervene if haemorrhage",
     "Avoids drugs; longer wait"],
]
mgmt_tbl = Table(mgmt_data, colWidths=[4*cm, 8.5*cm, 5*cm])
mgmt_tbl.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0),  colors.HexColor("#166534")),
    ("TEXTCOLOR",    (0,0), (-1,0),  WHITE),
    ("FONTNAME",     (0,0), (-1,0),  "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,-1), 8.5),
    ("ALIGN",        (0,0), (-1,-1), "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    ("ROWBACKGROUNDS",(0,1),(-1,-1), [GREEN_BG, WHITE]),
    ("BOX",          (0,0), (-1,-1), 1, BORDER),
    ("INNERGRID",    (0,0), (-1,-1), 0.5, BORDER),
    ("TOPPADDING",   (0,0), (-1,-1), 5),
    ("BOTTOMPADDING",(0,0), (-1,-1), 5),
    ("FONTNAME",     (0,1), (0,-1),  "Helvetica-Bold"),
]))
story.append(mgmt_tbl)
story.append(sp(4))
story.append(info_box(
    "<b>CAUTION:</b> Never give oxytocin BEFORE placental delivery — risk of trapping placental fragments "
    "or missing an undetected twin. Retained placenta (&gt;30 min) → risk of PPH 6x higher.",
    bg=RED_BG, border=colors.HexColor("#DC2626")
))

# ─────────────────────────────────────────────────────────────────────────────
# PAGE 4 — FOURTH STAGE + SUMMARY + KEY NUMBERS
# ─────────────────────────────────────────────────────────────────────────────
story.append(PageBreak())
story.append(section_header("FOURTH STAGE OF LABOUR — The Recovery Stage", colors.HexColor("#7C3AED")))
story.append(sp(5))

story.append(info_box(
    "<b>Definition:</b> The <b>first hour after delivery of the placenta</b> (described by Pritchard and MacDonald). "
    "This is the most critical period — risk of <b>Primary PPH</b> is highest during this hour. "
    "Uterine atony is the commonest cause.",
    bg=colors.HexColor("#EDE9FE"), border=colors.HexColor("#7C3AED")
))
story.append(sp(5))

story.append(Paragraph("Management During Fourth Stage", h3_style))
fourth_steps = [
    ("Inspect", "Cervix, vagina, vaginal walls, and perineum for lacerations → repair promptly"),
    ("Oxytocin infusion", "Promote uterine contraction and control haemorrhage"),
    ("Uterine tone check", "Frequent palpation; transabdominal massage if uterus relaxes"),
    ("Vital signs monitoring", "BP, pulse, temperature, respiratory rate every 15 minutes"),
    ("Bladder care", "Encourage voiding; catheterise if unable (full bladder displaces uterus → PPH)"),
    ("Blood loss assessment", "Normal: ≤500 mL. PPH = ≥500 mL blood loss"),
]
fourth_data = [["Action", "Details"]] + list(fourth_steps)
fourth_tbl = Table(fourth_data, colWidths=[4.5*cm, 13*cm])
fourth_tbl.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0),  colors.HexColor("#7C3AED")),
    ("TEXTCOLOR",    (0,0), (-1,0),  WHITE),
    ("FONTNAME",     (0,0), (-1,0),  "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,-1), 8.5),
    ("ALIGN",        (0,0), (0,-1),  "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    ("ROWBACKGROUNDS",(0,1),(-1,-1), [colors.HexColor("#EDE9FE"), WHITE]),
    ("BOX",          (0,0), (-1,-1), 1, BORDER),
    ("INNERGRID",    (0,0), (-1,-1), 0.5, BORDER),
    ("TOPPADDING",   (0,0), (-1,-1), 4),
    ("BOTTOMPADDING",(0,0), (-1,-1), 4),
    ("FONTNAME",     (0,1), (0,-1),  "Helvetica-Bold"),
    ("TEXTCOLOR",    (0,1), (0,-1),  colors.HexColor("#7C3AED")),
]))
story.append(fourth_tbl)
story.append(sp(8))

# MASTER SUMMARY TABLE
story.append(section_header("MASTER SUMMARY — All Four Stages", colors.HexColor("#1E3A5F")))
story.append(sp(5))
sum_data = [
    ["Feature", "1st Stage", "2nd Stage", "3rd Stage", "4th Stage"],
    ["From",
     "Onset of labour",
     "Full dilatation",
     "Delivery of baby",
     "Delivery of placenta"],
    ["To",
     "Full dilatation\n(10 cm)",
     "Delivery of baby",
     "Delivery of\nplacenta",
     "1 hour\npost-delivery"],
    ["Duration\n(Nullipara)",
     "~11 hours",
     "~54 minutes",
     "< 30 min",
     "1 hour"],
    ["Duration\n(Multipara)",
     "~7 hours",
     "~20 minutes",
     "< 10 min",
     "1 hour"],
    ["Key events",
     "Effacement +\nDilatation",
     "Cardinal\nmovements,\nDelivery of head",
     "Placental\nseparation",
     "Haemostasis,\nRepair"],
    ["Main risk",
     "Dystocia,\nFetal distress",
     "PPH, cord\nprolapse,\nlacerations",
     "PPH, retained\nplacenta",
     "PPH,\nUterine atony"],
]
sum_tbl = Table(sum_data, colWidths=[3.2*cm, 3.5*cm, 3.5*cm, 3.5*cm, 3.8*cm])
sum_tbl.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0),  NAVY),
    ("TEXTCOLOR",    (0,0), (-1,0),  WHITE),
    ("FONTNAME",     (0,0), (-1,0),  "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,-1), 8),
    ("ALIGN",        (0,0), (-1,-1), "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    ("ROWBACKGROUNDS",(0,1),(-1,-1), [LIGHT_BLUE, WHITE]),
    ("BOX",          (0,0), (-1,-1), 1.5, NAVY),
    ("INNERGRID",    (0,0), (-1,-1), 0.5, BORDER),
    ("TOPPADDING",   (0,0), (-1,-1), 5),
    ("BOTTOMPADDING",(0,0), (-1,-1), 5),
    ("FONTNAME",     (0,1), (0,-1),  "Helvetica-Bold"),
    ("TEXTCOLOR",    (0,1), (0,-1),  NAVY),
    # Highlight risk row
    ("BACKGROUND",   (0,6), (-1,6),  RED_BG),
]))
story.append(sum_tbl)
story.append(sp(8))

# KEY NUMBERS BOX
story.append(Paragraph("Key Numbers to Remember", h2_style))
story.append(sp(3))
kn_data = [
    ["Parameter", "Value"],
    ["Full cervical dilatation",                    "10 cm"],
    ["Active phase begins at",                       "3–4 cm"],
    ["Normal dilatation rate (Nullipara)",            "≥ 1.2 cm/hr"],
    ["Normal dilatation rate (Multipara)",            "≥ 1.5 cm/hr"],
    ["Prolonged latent phase (Nullipara)",            "> 20 hours"],
    ["Prolonged latent phase (Multipara)",            "> 14 hours"],
    ["Arrest of active phase",                        "No change ≥ 2 hours"],
    ["Prolonged 2nd stage (Nullipara, no epidural)", "> 2 hours"],
    ["Prolonged 2nd stage (Multipara)",               "> 1 hour"],
    ["Retained placenta",                             "> 30 minutes"],
    ["Normal blood loss (vaginal delivery)",          "≤ 500 mL"],
    ["Primary PPH threshold",                         "≥ 500 mL"],
]
kn_tbl = Table(kn_data, colWidths=[11*cm, 6.5*cm])
kn_tbl.setStyle(TableStyle([
    ("BACKGROUND",   (0,0), (-1,0),  TEAL),
    ("TEXTCOLOR",    (0,0), (-1,0),  WHITE),
    ("FONTNAME",     (0,0), (-1,0),  "Helvetica-Bold"),
    ("FONTSIZE",     (0,0), (-1,-1), 8.5),
    ("ALIGN",        (1,1), (1,-1),  "CENTER"),
    ("VALIGN",       (0,0), (-1,-1), "MIDDLE"),
    ("ROWBACKGROUNDS",(0,1),(-1,-1), [LIGHT_BLUE, WHITE]),
    ("BOX",          (0,0), (-1,-1), 1, TEAL),
    ("INNERGRID",    (0,0), (-1,-1), 0.5, BORDER),
    ("TOPPADDING",   (0,0), (-1,-1), 4),
    ("BOTTOMPADDING",(0,0), (-1,-1), 4),
    ("FONTNAME",     (1,1), (1,-1),  "Helvetica-Bold"),
    ("TEXTCOLOR",    (1,1), (1,-1),  NAVY),
]))
story.append(kn_tbl)
story.append(sp(5))

# Footer note
story.append(HRFlowable(width="100%", thickness=0.5, color=BORDER))
story.append(sp(3))
story.append(Paragraph(
    "Sources: Creasy &amp; Resnik's Maternal-Fetal Medicine (7e); Rosen's Emergency Medicine; "
    "Tintinalli's Emergency Medicine. Content aligned with DC Dutta's Textbook of Obstetrics framework.",
    small_style))

# ── Build ─────────────────────────────────────────────────────────────────────
doc.build(story)
print(f"PDF created: {OUTPUT}")

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