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Give me a flow chart regarding stages of labour in obg

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I now have all the clinical data I need from the textbooks. Let me build a detailed, well-structured flowchart as an image.
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Now I have all the data. Let me generate a comprehensive flowchart.
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A detailed medical flowchart titled "Stages of Labour" for obstetrics and gynecology. The chart flows vertically top to bottom with clearly labeled boxes and arrows. Use a clean clinical style with color-coded stages. Layout: Top: START box "ONSET OF LABOUR" (regular painful uterine contractions + cervical changes) STAGE 1 - FIRST STAGE (pale blue section header) Split into two sub-phases: Left sub-box: "LATENT PHASE" - Cervical dilation: 0 to 3-4 cm - Cervical effacement and softening - Duration: up to 20 hrs (nullipara), up to 14 hrs (multipara) - Irregular to regular contractions - Mild-moderate intensity Right sub-box: "ACTIVE PHASE" - Cervical dilation: 4 cm to 10 cm (full) - Rate: ≥1.2 cm/hr (nullipara), ≥1.5 cm/hr (multipara) - Duration: ~4.6 hrs (nullipara), ~2.4 hrs (multipara) - Regular contractions, 3-5 min apart - Cardinal movements begin: Engagement → Descent → Flexion → Internal rotation Arrow down to: STAGE 2 - SECOND STAGE (pale green section) Box: "FULL DILATION TO DELIVERY OF BABY" - Cervix fully dilated (10 cm) - Active maternal pushing - Cardinal movements: Extension → External rotation → Expulsion - Duration: avg 50 min (nullipara), avg 20 min (multipara) - FHR auscultation every 15 min (low risk), every 10 min (high risk) - Ends with DELIVERY OF BABY Arrow down to: STAGE 3 - THIRD STAGE (pale orange section) Box: "DELIVERY OF PLACENTA" - Begins after baby delivered - Signs of placental separation: cord lengthening, gush of blood, uterus fundus shape change - Active management: Oxytocin + controlled cord traction + uterine massage - Duration: up to 30 minutes - Ends with DELIVERY OF PLACENTA Arrow down to: STAGE 4 - FOURTH STAGE (pale yellow section) Box: "IMMEDIATE POSTPARTUM - 1st HOUR" - Monitor for PPH, uterine atony - Vital signs monitoring - Uterine massage - Oxytocin IV/IM if needed - Perineal repair (episiotomy/lacerations) Side notes with warning icons for abnormalities: - Prolonged latent phase (>20 hrs nullipara, >14 hrs multipara) - Arrested active phase (no dilation ≥2 hrs) - Protracted active phase (<1.2 cm/hr nullipara) - Second stage >2 hrs without epidural (nullipara) = alert for CPD Bottom box: "NORMAL LABOUR COMPLETE" Use medical color coding: blue for Stage 1, green for Stage 2, orange for Stage 3, yellow for Stage 4. Clear arrows, readable font size, professional medical diagram style.

Now I have all the data. Let me generate a comprehensive flowchart.
Stages of Labour Flowchart
Here is a full breakdown of each stage based on Creasy & Resnik's Maternal-Fetal Medicine and Textbook of Family Medicine (9e):

Stages of Labour - Summary

FIRST STAGE: Onset of Labour → Full Cervical Dilation (10 cm)

Latent Phase
  • Cervical dilation: 0 to 3-4 cm
  • Cervical effacement, softening, anterior positioning
  • Duration: up to 20 hrs (nullipara) / up to 14 hrs (multipara)
  • Contractions become regular but mild-moderate
  • Best managed at home; hospital if: bleeding, SROM, contractions 3-4 min apart, decreased fetal movement
Active Phase
  • Dilation: 4 cm → 10 cm (full)
  • Rate: ≥ 1.2 cm/hr (nullipara), ≥ 1.5 cm/hr (multipara) - Friedman curve
  • Duration: ~4.6 hrs (nullipara), ~2.4 hrs (multipara)
  • Cardinal movements begin: Engagement → Descent → Flexion → Internal rotation
  • FHR monitoring every 30 min (low risk), every 15 min (high risk)
Abnormalities of First Stage:
  • Prolonged latent phase: > 20 hrs (nullipara) / > 14 hrs (multipara) - treat with morphine
  • Protracted active phase: dilation < 1.2 cm/hr (nullipara) or < 1.5 cm/hr (multipara)
  • Arrest of active phase: no dilation for ≥ 2 hours

SECOND STAGE: Full Dilation → Delivery of Baby

  • Active maternal expulsive forces (pushing)
  • Cardinal movements continue: Extension → External rotation → Expulsion
  • Duration: avg 50 min (nullipara) / avg 20 min (multipara)
  • FHR auscultated every 15 min (low risk) / every 10 min (high risk)
  • Alert if pushing > 2 hrs without epidural OR > 3 hrs with epidural (nullipara) - possible CPD

THIRD STAGE: Delivery of Baby → Delivery of Placenta

  • Signs of placental separation: cord lengthening, gush of blood, change in fundal contour
  • Active management: Oxytocin + controlled cord traction + uterine massage
  • Duration: typically within 30 minutes
  • Inspect for vaginal/cervical tears after placenta delivers

FOURTH STAGE: 1st Hour After Placental Delivery (Pritchard & MacDonald)

  • Monitor for PPH, uterine atony, vital signs
  • Uterine massage; oxytocin 20-40 units/L IV or 20 units IM
  • Alternatives: methylergonovine 0.2 mg IM (if not hypertensive); PGF₂α (Hemabate) 250 mcg IM
  • Misoprostol 200-1000 mcg (oral/SL/vaginal/rectal) - widely used off-label
  • Repair of episiotomy and perineal lacerations
Sources: Textbook of Family Medicine 9e (Rakel); Creasy & Resnik's Maternal-Fetal Medicine, Principles and Practice
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