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pres.title = "NST Reading & Partograph Charting";
pres.author = "Medical Education";

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// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 1: Title
// ──────────────────────────────────────────────────────────────────────────────
addTitleSlide(pres,
  "NST & Partograph Charting",
  "Fetal Surveillance & Labor Monitoring for Medical Students"
);

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE 2: Overview / Agenda
// ──────────────────────────────────────────────────────────────────────────────
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    { num: "01", label: "Non-Stress Test (NST)", sub: "Purpose, setup, technique" },
    { num: "02", label: "Reading the NST Strip", sub: "Reactive vs. non-reactive, interpretation" },
    { num: "03", label: "NST Management", sub: "What to do with results" },
    { num: "04", label: "Introduction to Partograph", sub: "Purpose, WHO framework" },
    { num: "05", label: "Charting the Partograph", sub: "Components, plotting, alert/action lines" },
    { num: "06", label: "Interpreting Abnormal Labor", sub: "Prolonged labor, dystocia, interventions" },
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// ──────────────────────────────────────────────────────────────────────────────
// SECTION DIVIDER: NST
// ──────────────────────────────────────────────────────────────────────────────
addSectionDivider(pres, "1", "Non-Stress Test (NST)", "Antepartum fetal surveillance using fetal heart rate monitoring");

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: What is the NST?
// ──────────────────────────────────────────────────────────────────────────────
addContentSlide(pres, "What is the Non-Stress Test (NST)?", [
  "The NST monitors fetal heart rate (FHR) accelerations associated with fetal movements",
  "Introduced in the USA in the early 1970s — now the workhorse of antepartum fetal surveillance",
  "Based on the principle: FHR accelerations with movement indicate an intact neurological pathway and adequate oxygenation",
  "Absent or infrequent FHR accelerations correlate with progressive fetal hypoxia",
  "Non-invasive, no known contraindications — can begin as early as 26 weeks; routinely used from 32 weeks",
  "Usually the first-line test in high-risk pregnancy evaluation",
], { note: "Source: Pfenninger & Fowler's Procedures for Primary Care, 3rd Ed." });

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Indications
// ──────────────────────────────────────────────────────────────────────────────
addContentSlide(pres, "Indications for NST", [
  "Suspected or confirmed Intrauterine Growth Restriction (IUGR) — may also use umbilical artery Doppler",
  "Maternal or gestational diabetes mellitus",
  "Hypertensive disorders of pregnancy (gestational HTN, preeclampsia, chronic HTN)",
  "Prolonged or post-term pregnancy (>41 weeks)",
  "Decreased fetal movement reported by mother",
  "Maternal trauma",
  "Other high-risk conditions: renal disease, multiple gestation, substance abuse, prior fetal demise",
  "Testing frequency: twice-weekly for high-risk cases; daily or more frequently for severe preeclampsia remote from term",
], { note: "Interval originally set at 7 days; more frequent testing now advocated for deteriorating conditions" });

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Equipment & Setup
// ──────────────────────────────────────────────────────────────────────────────
addContentSlide(pres, "Equipment & Patient Setup", [
  "External fetal heart rate monitor (Doppler transducer) + tocodynamometer for uterine contractions",
  "Blood pressure cuff — check BP every 10-15 min during the test",
  "Ultrasonic gel, event marker button for patient to record fetal movement",
  "Fetal stimulation device: vibroacoustic stimulator (VAS) / artificial larynx",
  "Bed or reclining chair",
  "",
  "Patient Positioning:",
  "  • Semi-recumbent (semi-Fowler's) at 30-45°, slightly tilted left",
  "  • Or seated in reclining chair — NEVER flat supine (causes supine hypotension → false non-reactive result)",
  "",
  "Pre-test instructions: eat ~2 hours before, avoid sedatives/narcotics, remain sedentary 1 hour before",
], { note: "Medications such as narcotics and barbiturates can suppress FHR reactivity — always document current medications" });

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Technique Step by Step
// ──────────────────────────────────────────────────────────────────────────────
addContentSlide(pres, "NST Technique — Step by Step", [
  "1. Position patient in semi-recumbent position with left lateral tilt",
  "2. Apply external Doppler and tocodynamometer; record baseline BP",
  "3. Ask patient to press event marker button each time she feels fetal movement",
  "4. Monitor for a baseline 30-minute period",
  "5. If non-reactive in first 30 min → extend monitoring for up to 90 minutes total",
  "6. If still insufficient movement → use VAS (vibroacoustic stimulation) for 3 seconds; may repeat up to 3 times",
  "   - VAS shortens average NST duration from 24 → 15 minutes",
  "   - Does NOT decrease sensitivity or increase false-reactive results",
  "7. Interpret the tracing (reactive vs. non-reactive criteria)",
], { note: "VAS evidence: multiple RCTs support use for inducing fetal movements without compromising test sensitivity (ACOG)" });

// ──────────────────────────────────────────────────────────────────────────────
// SECTION DIVIDER: Reading NST
// ──────────────────────────────────────────────────────────────────────────────
addSectionDivider(pres, "2", "Reading the NST Strip", "Criteria for reactive, non-reactive, and equivocal results");

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Reactive NST Criteria
// ──────────────────────────────────────────────────────────────────────────────
addContentSlide(pres, "Reactive (Normal) NST — Criteria", [
  "TERM (≥32 weeks): At least 2 FHR accelerations within a 20-minute window",
  "  • Each acceleration must rise ≥15 bpm above baseline",
  "  • Each must last ≥15 seconds and <2 minutes",
  "  • ACOG: accelerations WITHOUT fetal movement also count as reactive",
  "",
  "PRETERM (<32 weeks): Lower criteria apply",
  "  • Acceleration of ≥10 bpm above baseline",
  "  • Lasting ≥10 seconds",
  "  • (NICHD 1997 definition)",
  "",
  "Key principle: Reactivity indicates intact neurological pathway, fetal arousal, and adequate oxygenation",
], { note: "Source: Pfenninger & Fowler's Procedures for Primary Care; Creasy & Resnik's Maternal-Fetal Medicine" });

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: NST Tracing image
// ──────────────────────────────────────────────────────────────────────────────
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  sl.addText([
    { text: "A - REACTIVE\n", options: { bold: true, breakLine: true } },
    { text: "• ≥2 accelerations\n", options: { breakLine: true } },
    { text: "• ≥15 bpm rise\n", options: { breakLine: true } },
    { text: "• ≥15 sec duration\n", options: { breakLine: true } },
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    { text: "• Requires further evaluation\n", options: { breakLine: true } },
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// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Non-Reactive NST
// ──────────────────────────────────────────────────────────────────────────────
addContentSlide(pres, "Non-Reactive (Abnormal) NST", [
  "Definition: Does NOT meet criteria for reactive within 20-40 minute window",
  "Most common cause of non-reactivity: fetal sleep cycle (20-40 min cycles) — not pathological",
  "Management of non-reactive result:",
  "  • Extend observation to 90 minutes total",
  "  • Use VAS to stimulate fetus",
  "  • Check patient position (avoid supine hypotension → false positive)",
  "",
  "If persistently non-reactive after 90 minutes:",
  "  • Biophysical Profile (BPP)",
  "  • Contraction Stress Test (CST)",
  "  • Consider delivery if mature fetus with favorable cervix",
  "  • Modified BPP (NST + Amniotic Fluid Index) — false-negative rate 0.8 per 1000",
], { note: "Positive predictive value of abnormal NST: 15% (post-term) to 69% (IUGR) — false positives are common" });

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: NST Interpretation Summary Table
// ──────────────────────────────────────────────────────────────────────────────
addTableSlide(pres, "NST Interpretation — Quick Reference",
  ["Feature", "Reactive (Normal)", "Non-Reactive (Abnormal)"],
  [
    ["Accelerations", "≥2 in 20 min window", "< 2 accelerations"],
    ["Amplitude", "≥15 bpm rise", "< 15 bpm"],
    ["Duration", "≥15 sec, <2 min", "< 15 seconds"],
    ["Preterm (<32 wk)", "≥10 bpm for ≥10 sec", "Does not meet criteria"],
    ["Interpretation", "Reassuring — fetal wellbeing", "Further testing required"],
    ["False-negative rate", "2 per 1000", "Not applicable"],
    ["Next step if abnormal", "Extend / VAS / BPP / CST", "BPP, CST, or delivery"],
  ]
);

// ──────────────────────────────────────────────────────────────────────────────
// SECTION DIVIDER: PARTOGRAPH
// ──────────────────────────────────────────────────────────────────────────────
addSectionDivider(pres, "3", "Partograph Charting", "Monitoring labor progress and maternal-fetal wellbeing");

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: What is a Partograph?
// ──────────────────────────────────────────────────────────────────────────────
addContentSlide(pres, "What is a Partograph?", [
  "A graphical tool for monitoring, recording, and evaluating progress of labor and maternal-fetal condition",
  "Used during the ACTIVE PHASE of the first stage of labor",
  "Central feature: a cervicograph — graphical recording of cervical dilation over time",
  "WHO introduced the partograph in 1972; multiple revisions since (1994, 2000, 2018 Labor Care Guide)",
  "Designed for use at ANY level of care — from health centers to tertiary hospitals",
  "Purpose: early detection of prolonged labor, maternal deterioration, fetal compromise",
  "Evidence: WHO multicenter trial (1994) showed partograph use reduced prolonged labor, emergency C-sections, and fetal asphyxia",
], { note: "WHO Labor Care Guide (LCG) is the 2018 evolution of the partograph with woman-centered additions" });

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Components of Partograph
// ──────────────────────────────────────────────────────────────────────────────
addContentSlide(pres, "Components of the WHO Partograph", [
  "SECTION 1 — Patient Information: Name, parity, hospital number, date/time of admission, time of ruptured membranes",
  "",
  "SECTION 2 — Fetal Condition:",
  "  • Fetal Heart Rate (FHR) — recorded every 30 minutes (normal: 110-160 bpm)",
  "  • Liquor (amniotic fluid): I = intact, C = clear, M = meconium, A = absent",
  "  • Moulding: 0, +, ++, +++ (overlapping of fetal skull bones)",
  "",
  "SECTION 3 — Labor Progress (the CERVICOGRAPH):",
  "  • Cervical dilation plotted with 'X' — start at 4-5 cm active phase",
  "  • Descent of fetal head plotted with 'O' (in fifths above pelvic brim)",
  "  • Uterine contractions: frequency, duration, intensity (shading)",
  "",
  "SECTION 4 — Medications: Oxytocin, IV fluids, drugs given",
  "",
  "SECTION 5 — Maternal Condition: BP, pulse, temperature, urine output, protein, acetone",
], { note: "Source: MSF Medical Guidelines; WHO Partograph Manual; Park's Textbook of Preventive & Social Medicine" });

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Alert and Action Lines
// ──────────────────────────────────────────────────────────────────────────────
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  // Three zones
  const zones = [
    { x: 0.3, color: C.green, title: "GREEN ZONE", sub: "Left of Alert Line", points: ["Normal labor progress", "Dilation ≥1 cm/hr", "Continue monitoring", "No intervention needed"] },
    { x: 3.65, color: C.amber, title: "AMBER ZONE", sub: "Between Alert & Action Lines", points: ["Labor slowing down", "Increased vigilance required", "Consider transfer if peripheral facility", "Prepare for possible intervention"] },
    { x: 7.0, color: C.red, title: "RED ZONE", sub: "Right of Action Line", points: ["Labor dangerously slow", "Immediate action required", "Augmentation (oxytocin/ARM)", "C-section if indicated"] },
  ];

  zones.forEach(z => {
    sl.addShape(pres.ShapeType.rect, { x: z.x, y: 0.95, w: 3.1, h: 4.45, fill: { type: "solid", color: z.color }, line: { color: z.color } });
    sl.addText(z.title, { x: z.x, y: 0.95, w: 3.1, h: 0.52, fontSize: 14, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle", margin: 0 });
    sl.addText(z.sub, { x: z.x + 0.05, y: 1.5, w: 3.0, h: 0.38, fontSize: 11, italic: true, color: C.white, fontFace: "Calibri", align: "center", margin: 0 });
    const pts = z.points.map((p, i) => ({ text: p, options: { bullet: { type: "bullet" }, fontSize: 13, color: C.white, fontFace: "Calibri", breakLine: i < z.points.length - 1, paraSpaceAfter: 6 } }));
    sl.addText(pts, { x: z.x + 0.1, y: 1.95, w: 2.9, h: 3.2, valign: "top", margin: [0, 6, 0, 6] });
  });

  sl.addText("Alert Line: from 4-5 cm dilation at 1 cm/hr rate  |  Action Line: 4 hours to the right of Alert Line", {
    x: 0.3, y: 5.12, w: 9.4, h: 0.45, fontSize: 11, italic: true, color: C.slate, fontFace: "Calibri", align: "center", margin: 0
  });
}

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Fetal Head Descent & Moulding
// ──────────────────────────────────────────────────────────────────────────────
addContentSlide(pres, "Fetal Head Descent & Moulding on Partograph", [
  "HEAD DESCENT — recorded as 'O' in fifths palpable above the pelvic brim:",
  "  5/5 = head entirely above pelvic brim (free/floating)",
  "  4/5 = just palpable above brim",
  "  3/5 = head at brim",
  "  2/5 = head entered pelvis",
  "  1/5 = most of head in pelvis",
  "  0/5 = head fully engaged / not palpable abdominally",
  "",
  "MOULDING — assesses overlap of fetal skull bones during labor:",
  "  0 = sutures felt separately (normal)",
  "  + = sutures just touching (acceptable)",
  "  ++ = sutures overlapping (concerning)",
  "+++ = severe overlapping (sign of cephalopelvic disproportion — urgent review)",
], { note: "Moulding >++ with failure to progress = strong indicator of CPD — consider operative delivery" });

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Uterine Contractions
// ──────────────────────────────────────────────────────────────────────────────
addContentSlide(pres, "Recording Uterine Contractions on the Partograph", [
  "Assessed every 30 minutes during active labor — record in the 10-minute grid",
  "Count: Number of contractions in 10 minutes",
  "Duration: How long each contraction lasts",
  "",
  "Intensity recorded by SHADING the box:",
  "  • Dotted/stippled box = <20 seconds (mild, short)",
  "  • Hatched/lined box = 20-40 seconds (moderate)",
  "  • Solid/filled box = >40 seconds (strong, prolonged)",
  "",
  "Normal active labor: 3-5 contractions per 10 minutes, lasting >40 seconds",
  "Hyperstimulation: >5 contractions per 10 minutes or contractions >90 sec (especially with oxytocin) — STOP oxytocin",
  "Inadequate contractions: <3 per 10 min of <40 sec → consider augmentation if labor not progressing",
], { note: "Always correlate contraction quality with cervical progress on the cervicograph" });

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Liquor and Fetal Heart Rate
// ──────────────────────────────────────────────────────────────────────────────
addTwoColumnSlide(pres,
  "Fetal Heart Rate & Liquor on Partograph",
  "Fetal Heart Rate (FHR)",
  [
    "Auscultate every 30 min in active phase (every 15 min in second stage)",
    "Record immediately AFTER a contraction",
    "Normal range: 110-160 bpm",
    "Bradycardia <110 bpm: fetal distress",
    "Tachycardia >160 bpm: infection, hypoxia, drugs",
    "Decelerations after contractions: late decels = uteroplacental insufficiency",
    "Variable decels: cord compression",
  ],
  "Amniotic Fluid (Liquor)",
  [
    "I = Intact membranes",
    "C = Clear fluid (normal)",
    "M = Meconium-stained (fetal distress risk)",
    "M+ or M++ = thick/particulate meconium — high risk",
    "A = Absent fluid (oligohydramnios, dry)",
    "Meconium + abnormal FHR = emergency — prepare for delivery",
    "Foul-smelling fluid suggests chorioamnionitis",
  ]
);

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Interpreting Abnormal Labor
// ──────────────────────────────────────────────────────────────────────────────
addContentSlide(pres, "Interpreting Abnormal Labor on Partograph", [
  "PROLONGED LATENT PHASE: >8 hours without entering active labor — assess, rehydrate, consider sedation/oxytocin",
  "",
  "ACTIVE PHASE DISORDERS:",
  "  • Protraction disorder: cervical dilation <1 cm/hr (crosses alert line) — assess CPD, augment if appropriate",
  "  • Arrest disorder: no dilation for ≥2 hours (crosses action line) — urgent review, consider C-section",
  "",
  "SECONDARY ARREST (second stage): No descent for >1 hr (nullipara) or >30 min (multipara) — assess position, consider instrumental/operative delivery",
  "",
  "Causes of failure to progress: Cephalopelvic Disproportion (CPD), malposition (OP, face), inefficient uterine activity, full bladder",
  "",
  "3 Ps Framework: Power (contractions), Passenger (position, moulding, size), Passage (pelvis)",
], { note: "Always review ALL partograph parameters together — no single finding in isolation drives management" });

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Maternal Vitals on Partograph
// ──────────────────────────────────────────────────────────────────────────────
addContentSlide(pres, "Maternal Monitoring on the Partograph", [
  "Blood Pressure: Every 30 minutes in active labor",
  "  • Hypertension ≥140/90: preeclampsia — urgent treatment, consider MgSO₄",
  "  • Hypotension: aortocaval compression, hemorrhage, epidural",
  "",
  "Pulse: Every 30 minutes",
  "  • Tachycardia >100 bpm: pain, dehydration, hemorrhage, sepsis",
  "",
  "Temperature: Every 4 hours (every 2 hours if membranes ruptured >18 hrs)",
  "  • Fever >38°C: chorioamnionitis — blood cultures, antibiotics, expedite delivery",
  "",
  "Urine: Volume, protein, acetone",
  "  • Proteinuria: preeclampsia",
  "  • Ketonuria: dehydration/starvation — IV fluids",
  "  • Oliguria <30 mL/hr: renal compromise, hemorrhage",
]);

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Clinical Decision Framework
// ──────────────────────────────────────────────────────────────────────────────
addTableSlide(pres, "Partograph Findings — Clinical Decision Guide",
  ["Finding", "Likely Cause", "Action"],
  [
    ["Dilation curve crosses Alert line", "Slow labor progress", "Increased monitoring; transfer if peripheral"],
    ["Dilation curve crosses Action line", "Prolonged labor / CPD", "Augment labor or C-section"],
    ["Moulding +++", "CPD / malposition", "Urgent obstetric review; consider C-section"],
    ["FHR <110 or >160 bpm", "Fetal distress", "Position change, O₂, stop oxytocin, delivery"],
    ["Thick meconium + abnormal FHR", "Severe fetal compromise", "Emergency delivery (LSCS or instrumental)"],
    ["Fever >38°C + purulent liquor", "Chorioamnionitis", "Antibiotics, expedite delivery"],
    ["BP ≥160/110 + proteinuria", "Severe preeclampsia", "MgSO₄, antihypertensives, deliver"],
  ]
);

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Key Differences — NST vs Partograph
// ──────────────────────────────────────────────────────────────────────────────
addTwoColumnSlide(pres,
  "NST vs. Partograph — At a Glance",
  "Non-Stress Test (NST)",
  [
    "WHEN: Antenatal (before labor onset)",
    "PURPOSE: Assess fetal wellbeing",
    "SETTING: OPD / antenatal clinic",
    "DURATION: 20-90 minutes",
    "MONITORS: Fetal heart rate + movements",
    "RESULT: Reactive (normal) or Non-reactive",
    "NEXT STEP if abnormal: BPP, CST, delivery",
  ],
  "Partograph",
  [
    "WHEN: During active labor",
    "PURPOSE: Monitor labor progress + fetal/maternal status",
    "SETTING: Labor ward / delivery room",
    "DURATION: Entire active labor phase",
    "MONITORS: Cervical dilation, descent, FHR, contractions, maternal vitals",
    "RESULT: Normal / Alert / Action zone",
    "NEXT STEP if abnormal: Augment or operative delivery",
  ]
);

// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: Summary & Key Take-aways
// ──────────────────────────────────────────────────────────────────────────────
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  const points = [
    { icon: "✦", text: "NST is REACTIVE when ≥2 FHR accelerations of ≥15 bpm lasting ≥15 sec occur within 20 min (term fetus)" },
    { icon: "✦", text: "A non-reactive NST most often reflects fetal sleep — extend monitoring or use VAS before declaring fetal distress" },
    { icon: "✦", text: "Modified BPP (NST + AFI) is highly sensitive with a false-negative rate of only 0.8 per 1000" },
    { icon: "✦", text: "Partograph is started at 4-5 cm cervical dilation (active phase of labor)" },
    { icon: "✦", text: "Alert line = 1 cm/hr dilation rate from 4-5 cm; Action line is 4 hours to the right" },
    { icon: "✦", text: "Crossing the action line demands immediate decision: augmentation, ARM, or C-section" },
    { icon: "✦", text: "Always assess the 3 Ps when labor fails to progress: Power, Passenger, Passage" },
  ];

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// ──────────────────────────────────────────────────────────────────────────────
// SLIDE: References
// ──────────────────────────────────────────────────────────────────────────────
addContentSlide(pres, "References", [
  "Pfenninger & Fowler's Procedures for Primary Care, 3rd Edition — Chapter 165: Non-Stress Test",
  "Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice — Fetal Heart Rate Monitoring",
  "Tietz Textbook of Laboratory Medicine, 7th Edition — Laboratory Testing in Pregnancy",
  "Park's Textbook of Preventive and Social Medicine — Maternal Health & Intra-natal Care",
  "WHO Partograph Manual (1994 multicenter trial; 2000 simplified partograph)",
  "MSF Medical Guidelines 5.2 — Monitoring Labour and Delivery",
  "WHO Intrapartum Care Guidelines 2018 — Labor Care Guide (LCG)",
  "ACOG Practice Bulletins — Antepartum Fetal Surveillance",
  "NICHD (1997) — Fetal Heart Rate Monitoring Definitions",
], { note: "This presentation is intended for educational purposes for medical students. Clinical decisions must follow local guidelines." });

// ──────────────────────────────────────────────────────────────────────────────
// WRITE FILE
// ──────────────────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/nst-partograph-presentation/NST_and_Partograph.pptx" })
  .then(() => console.log("✅ PPTX written successfully"))
  .catch(err => { console.error("❌ Error:", err); process.exit(1); });