LESSON PLAN on partograph related to obstetrics

Obg

1. CHRISTIAN COLLEGE OF NURSING, NEYYOOR

LESSON PLAN






Submitted to Submitted by
Dr. Arzta Sophia Anne Jakuline Princy

2. Associate Professor II
nd
Year M.Sc Nursing

GENERAL OBJECTIVE:
After the completion of the planned teaching programme, there will be increase in the knowledge and improving
attitude of women regarding cervical cancer and its prevention.

SPECIFIC OBJECTIVE:
After completion of planned teaching programme women will be able to:
 to introduce the topic.
 to explain about the definition of cervical cancer.
 to discuss the etiology and risk factor of cervical cancer.
 to detail about the sign and symptoms of cervical cancer
 to describe the stages of developing cervical cancer in body.
 to list out the diagnostic tests for cervical cancer.
 to interpret the management strategy of cervical cancer.
 to expound the prevention level of cervical cancer.

3. Sl.
NO.
SPECIFIC
OBJECTIVES
CONTENT Time
Teacher’s ,
Learner’s
Activity
Evaluation
INTRODUCTION
Cervical cancer starts in the cells lining the cervix-
the lower part of the uterus (womb).The cervix connects the
body of the uterus(the upper part where a fetus grows) to
the vagina (birth canal). Cancer starts when cells in the
body begin to grow out of control.
All women are at risk for cervical cancer. It occurs
most often in women over age 30.Long-lasting infection
with certain types of human papillomavirus (HPV)is the
main cause of cervical cancer. HPV is a common virus that
is passed from one person to another during sex. At least
half of sexually active people will have HPV at some point
in their lives, but few women will get cervical cancer

Screening tests and the human papillomavirus vaccine can

4. help prevent cervical cancer. When cervical cancer is found
early, it is highly treatable and associated with long survival
and good quality of life.

DEFINITION
Cervical cancer is the uncontrolled growth of abnormal
cells in the lining of the cervix. The cervix is part of the
female reproductive system and is located in the lower part
of the womb, forming the opening from the womb to the
vagina.

ETIOLOGY AND RISK FACTOR
A. Human papillamavirus infection (HPV)
 The most important risk factor for cervical cancer is
infection with Human Papillomavirus. Human
Papillomavirus is common. Most people become
infected with Human Papillomavirus when they
become sexually active, and most people clear the

5. virus without problems. There are over 100 different
types of Human Papillomavirus. Not all of them are
linked to cancer.
 The Human Papillomavirus types or strains that are
most frequently associated with cervical cancer are
Human Papillomavirus 16 and 18.
 Starting to have sex at an earlier age or having
multiple sexual partners puts a person at higher risk
of being infected with high-risk Human
Papillomavirus types.

B. Immune system deficiency
 People with lowered immune systems have a higher
risk of developing cervical cancer. A lowered
immune system can be caused by immune
suppression from corticosteroid medications, organ
transplantation, treatments for other types of cancer,
or from the human immunodeficiency virus (HIV),

6. which is the virus that causes acquired immune
syndrome (AIDS). deficiency
 When a person has human immunodeficiency virus,
their immune system is less able to fight off early
cancer.

C. Herpes
 Women who have genital herpes have a higher risk
of developing cervical cancer.

D. Age
 People younger than 20 years old rarely develop
cervical cancer. The risk goes up between the late
teens and mid-30s. Women past this age group
remain at risk and need to have regular cervical
cancer screenings, which include a Papanicolaou test
and/or a Human Papillomavirus test.

7. E. Socioeconomic factors
 Cervical cancer is more common among groups of
women who are less likely to have access to
screening for cervical cancer. Those populations are
more likely to include Black women, Hispanic
women, American, Indian women, and women from
low- income households.

F. Oral contraceptives
 Some research studies suggest that oral
contraceptives, which are birth control pills, may be
associated with an increased risk of cervical cancer
and may be associated with higher-risk sexual
behavior.

G. Exposure to diethylstilbestrol (DES)
 Women whose mothers were given this drug during
pregnancy to prevent miscarriage have an increased

8. risk of developing a rare type of cancer of the cervix
or vagina. Diethylstilbestrol was given for this
purpose from about 1940 to 1970.
 Women exposed to diethylstilbestrol should have an
annual pelvic examination that includes a cervical
Papanicolaou test.

SIGN AND SYMPTOMS
A. Abnormal pain or bleeding
Irregular bleeding is considered the most common
symptom in women with cervical cancer. Bleeding or pain
may occur between menstrual periods, after sexual
intercourse, or in postmenopausal women.

B. Abnormal discharge
 An unusual discharge from the vagina is another serious
sign of cervical cancer. When cancer starts to grow in
the cervix, the uterine wall cells begin to produce a

9. watery discharge after menopause and between your
menstrual periods.
 It is possible that the discharge may look yellowish,
pale, or brownish, and it may contain some blood.

C. Urination discomfort
 Problems or discomfort with urinating is often a sign
of a urinary tract infection. Women have a high risk
of urinary tract infections, and 50% experience repeat
infections that sometimes occur every year. However,
in other cases, urination discomfort is a sign that
cervical cancer has spread to the bladder. A hint of
blood may also be seen in the urine. This is a clear
warning sign of cervical cancer.

D. Genital warts
 Small genital warts can be considered a red warning
flag for human papillomavirus, which can

10. significantly increase the risk of cervical cancer in
women. There are many different types of human
papillomavirus, but human papillomavirus -6 and 11
are known to cause 90% of every form of genital
warts.

E. Unusually heavy and long menstrual periods
 Women with cervical cancer will also have
abnormally long and heavy menstrual periods.

F. Lack of urinary control
 When the cervix swells, the bladder and kidneys may
be compressed. As a result, urine flow is obstructed
not be able to control bladder. Women with cervical
cancer will have that sudden urge to urinate. As
mentioned, patients with cervical cancer will also see
blood in the urine.

11. G. Pain during sex
 Pain during sex is considered a symptom during the
late stages of cervical cancer.

H. Anemia
 Feeling constantly fatigued and weak is often a sign
of anemia. Heart rate may also increase from normal
activities. Experience other common symptoms of
anemia, such as shortness of breath after mild
exertion, headaches, dizziness or fainting,
concentrating problems, cold extremities, frequent
colds, and pale skin, lips, and nails. Anemia is a
common symptom of abnormal bleeding, which is
also a cause of cervical cancer.

I. Weight loss
 Unexpected and sudden weight loss can be a sign that

12. the body is fighting off disease. Many cancers are
known to suppress or lower your appetite. When the
cervix swells, the stomach is compressed. As a result,
the person will experience weight loss and a reduced
appetite.

J. Constant pain in the back, hips, and legs
 The swelling of the cervix will also compress the
internal organs and the blood vessels. As a result, it is
difficult for blood to flow to the legs and pelvis. The
person will then experience body swelling and pain
in the pelvis, legs, ankles, hips, or back.


STAGES
 Stage 0: Abnormal cells are found only in the first
layer of the cells lining the cervix.
 Stage 1: The cancer is found only in the tissues of

13. the cervix
 Stage 2: The tumor has spread beyond the cervix to
the vagina and tissues next to the cervix
 Stage 3: The cancer has spread throughout the pelvic
area
 Stage 4: The cancer has spread beyond the pelvic
area to nearby organs such as the bladder or rectum.
The tumor may also have spread to the lung, liver or
bones

DIAGNOSTIC EVALUATION
A. Bimanual pelvic examination and sterile speculum
examination.
 In this examination, the doctor will check for any
unusual changes in the patient's cervix, uterus,
vagina, ovaries, and other nearby organs.

B. Papanicolaou test(Pap test).

14.  During a Pap test, the doctor gently scrapes the
outside and inside of the cervix, taking samples of
cells for testing.

C. Human Papillomavirus test (HPV typing test)
 An HPV test is similar to a Pap test. The test is done
on a sample of cells from the cervix. The doctor may
test for HPV at the same time as a Pap test or after
Pap test results show abnormal changes to the cervix.

D. Colposcopy
 To check the cervix for abnormal areas. Colposcopy
can also be used to help guide a biopsy of the cervix.
During a colposcopy, a special instrument called a
colposcope is used. The colposcope magnifies the
cells of the cervix and vagina, similar to a
microscope.

15. E. Biopsy
 A biopsy is the removal of a small amount of tissue
for examination under a microscope. Other tests can
suggest that cancer is present, but only a biopsy can
make a definite diagnosis. A pathologist then
analyzes the sample and evaluating tissues, and
organs to diagnose disease. If the lesion is small, the
doctor may remove all of it during the biopsy.
 Most are usually done in the doctor's office,
sometimes using a local anesthetic to numb the area.
There may be some bleeding and other discharge
after a biopsy, discomfort similar to menstrual
cramps.
 One common biopsy method uses an instrument to
pinch off small pieces of cervical tissue. Other types
of biopsies include:

1. Endocervical curettage (ECC).

16.  To check an area inside the opening of the cervix that
cannot be seen during a colposcopy. During this
procedure, the doctor uses a small, spoon-shaped
instrument called a curette to scrape a small amount
of tissue from inside the cervical opening.

2. Loop electrosurgical procedure (LEEP) excision
 . Uses an electrical current passed through a thin wire
hook. The hook removes tissue for examination in
the aboratory. A LEEP may also be used to remove a
precancer or an early-stage cancer.

3. Conization (a cone biopsy).
 This removes a cone-shaped piece of tissue from the
cervix. Conization may be done as treatment to
remove a precancer or an early-stage cancer. It is
done under a general or local anesthetic and may be
done in the doctor's office or the hospital.

17. F. Pelvic examination under anesthesia
 In cases where it is necessary for treatment planning,
the specialist may re-examine the pelvic area while
the patient is under anesthesia to see if the cancer has
spread to any organs near the cervix, including the
uterus, vagina, bladder, or rectum.

G. X-ray
 An x-ray is a way to create a picture of the structures
inside of the body using a small amount of radiation.
An intravenous urography is a type of x- ray that is
used to view the kidneys and bladder.

H. Computed tomography (CT or CAT)
scan
 3-dimensional image that shows any abnormalities or

18. tumors. A CT scan can be used to measure the
tumor's size.
 Sometimes, a special dye called contrast medium is
given before the scan to provide better detail on the
image. This dye can be injected into a patient's vein
or given as a pill or liquid to swallow.
I. Magnetic resonance imaging
 MRI can be used to measure the tumor's size. A
special dye called a contrast medium is given before
the scan to create a clearer picture. This dye can be
injected into a patient's vein or given as a pill or
liquid to swallow.

J. Positron emission tomography (PET) or PET-CT scan
 A PET scan is a way to create pictures of organs and
tissues inside the body. A small amount of a
radioactive sugar substance is injected into the
patient's body. This sugar substance is taken up by

19. cells that use the most energy. Because cancer tends
to use energy actively, it absorbs more of the
radioactive substance. A scanner then detects this
substance to produce images of the inside of the
body.

K. Molecular testing of the tumor
 To identify specific genes, proteins, and other factors
unique to the tumor. Results of these tests can help
determine treatment options.
 If there are signs or symptoms of bladder or rectal
problems:

L. Cystoscopy
 To view the inside of the bladder and urethra with a
thin, lighted tube called a cystoscope. The person
may be sedated as the tube is inserted in the urethra.
A cystoscopy is used to determine whether cancer

20. has spread to the bladder.

M. Sigmoidoscopy
 To see the colon and rectum with a thin, lighted,
flexible tube called a sigmoidoscope. The person may
be sedated as the tube is inserted in the rectum. A
sigmoidoscopy is used to see if the cancer has spread
to the rectum.

MANAGEMENT
The treatment of cervical cancer depends on several factors,
including the type and stage of cancer, possible side effects,
and the patient's preferences and overall health.
1. Surgery
2. Radiation therapy
3. Systematic therapy
1. Surgery
A. Conization

21. The use of the same procedure as a cone biopsy to
remove all of the abnormal tissue.

B. loop electrosurgical excision procedure
The use of an electrical current passed through a thin
wire hook. The hook removes the tissue.

C. Hysterectomy
 The removal of the uterus and cervix. Hysterectomy
can be either simple or radical.
 A simple hysterectomy is the removal of the uterus
and cervix.
 A radical hysterectomy is the removal of the uterus,
cervix, upper vagina, and the tissue around the
cervix.
D. Bilateral salpingo-oophorectomy
 The removal of both fallopian tubes and both ovaries.

22. E. Radical trachelectomy
 A surgical procedure in which the cervix is removed,
but the uterus is left intact. It includes pelvic lymph
node dissection. This surgery may be used for young
patients who want to preserve their fertility.

F. Exenteration
 The removal of the uterus, vagina, lower colon,
rectum, or bladder if cervical cancer has spread to
these organs after radiation therapy. Exenteration is
rarely recommended. It is most often used for some
people whose cancer has come back after radiation
treatment.
2. Radiation therapy
 Radiation therapy is the use of high- energy x-rays or
other particles to destroy cancer cells. Radiation
therapy may be given alone, before surgery, or
instead of surgery to shrink the tumor.

23.  The most common type of radiation treatment is
called external-beam radiation therapy, which is
radiation given from a machine outside the body.
When radiation treatment is given using implants, it
is called internal radiation therapy or brachytherapy.
 For early stages of cervical cancer, a combination of
radiation therapy and low-dose weekly chemotherapy
is often used. The goal of radiation therapy combined
with chemotherapy is to increase the effectiveness of
the radiation treatment.
 This combination is given to control the cancer in the
pelvis with the goal of curing the cancer without
surgery. It may also be given to destroy microscopic
cancer that might remain after surgery.
 Side effects from radiation therapy may include
fatigue, mild skin reactions, upset stomach, and loose
bowel movements. Side effects of internal radiation
therapy may include abdominal pain and bowel

24. obstruction, although it is uncommon. Most side
effects usually go away after treatment is finished.
Women who have received external-beam radiation
therapy will lose the ability to become pregnant, and
unless the ovaries have been surgically moved out of
the pelvis, premenopausal women will enter
menopause.

3. Systemic therapy
 Systemic therapy is the use of medication to destroy
cancer cells. This type of medication is given through
the bloodstream to reach cancer cells throughout the
body.
 Common ways to give systemic therapies include an
intravenous (IV) tube placed into a vein using a
needle or in a pill or capsule that is swallowed
(orally).
 The types of systemic therapies used for cervical

25. cancer include:

1. Chemotherapy
 Chemotherapy is the use of drugs to destroy cancer
cells, usually by keeping the cancer cells from
growing, dividing, and making more cells.
 A chemotherapy regimen, or schedule, usually
consists of a specific number of cycles given over a
set period of time. A patient may receive 1 drug at a
time or a combination of different drugs given at the
same time. For women with cervical cancer,
chemotherapy is often given in combination with
radiation therapy.
 The side effects of chemotherapy depend on the
individual and the dose used, but they can include
fatigue, risk of infection, nausea and vomiting, hair
loss, loss of appetite, and diarrhea. These side effects
usually go away after treatment is finished.

26. 2. Targeted therapy
Targeted therapy is a treatment that targets the cancer's
specific genes, proteins, or the tissue environment that
contributes to cancer growth and survival. This type of
treatment blocks the growth and spread of cancer cells and
limits damage to healthy cells.
 To find the most effective treatment, doctor may run
tests to identify the genes, proteins, and other factors
in your tumor. This helps doctors better match each
patient with the most effective treatment whenever
possible.

3. Immunotherapy
Immunotherapy, also called biologic therapy, is
designed to boost the body's natural defenses to fight the
cancer. It uses materials made either by the body or in a
laboratory to improve, target, or restore immune system

27. function.
Different types of immunotherapy can cause different
side effects. Common side effects include skin reactions,
flu- like symptoms, diarrhea, and weight changes.

PREVENTION
 World Health Organization recommends a
comprehensive approach to cervical cancer
prevention and control that includes three
interdependent components: primary, secondary and
tertiary prevention.

1. Primary prevention: reduce the risk of Human
Papillomavirus infection
 It begins with Human Papillomavirus vaccination of
girls aged 9-13 years, before they become sexually
active. Two Human Papillomavirus vaccines are
there - a bivalent and a quadrivalent vaccine. The

28. quadrivalent vaccine gives 100% protection against
infection from Human Papillomavirus types 16 and
18, which are responsible for around 70% of all
cervical cancers. It also protects against Human
Papillomavirus types 6 and 11 that cause genital
warts. The vaccination schedule depends on the age
of the vaccine recipient.
2. Secondary prevention: screening for and treating pre-
cancer
 Early detection, by screening all women in the target
age group (30-49 years) followed by treatment of
detected precancerous lesions can prevent the
majority of cervical cancers. Cervical cancer
screening should be an essential part of a woman's
routine health care. It detects pre-cancer and cancer
among women who have no symptoms and may feel
perfectly healthy. Important aspect of screening is
that both precancerous lesions and early cervical

29. cancers can be treated very successfully at this stage.

3. Tertiary prevention: treatment of invasive cervical
cancer
 The goal of tertiary prevention is to decrease the
number of deaths due to cervical cancer. Women
suspected of having invasive cervical cancer should
be referred to facilities that offer cancer diagnosis
and treatment.
 Appropriate treatment in early stage of cancer can
result in cure. In advanced stage of cancer treatment
and palliative care can improve quality of life,
control symptoms and minimize pain suffering.

Five key messages by World Health Organization;
1. Cervical cancer is a disease that can be prevented.
2. There are tests to detect early changes in the cervix
(known as pre-cancers) that may lead to cancer if not

30. treated.
3. There are safe and effective treatments for these early
changes.
4. All women aged 30-49 years should be screened for
cervical cancer at least once.
5. There is a vaccine for girls that can help prevent cervical
cancer.

SUMMARY
So today we have discussed about the what is cervical
cancer, etiology and risk factors, sign and symptoms,
diagnostic evaluation, management and how to prevent it.