KENYA METHODIST UNIVERSITY

SCHOOL OF MEDICINE AND HEALTH SCIENCES

DEPARTMENT- NURSING
NAME :MYATU JAPHETH MULWA

REGISTRATION: BSN-1-8145-3/2019

COURSE TITLE: REPRODUCTIVE HEALTH NURSING 1 (CLINICALS)

COURSE CODE: NRSG 242

INSTRUCTOR: MADAM ROSELYNE ODHIAMBO

TOPIC: CASE STUDY ON VAGINAL CANDIDIASIS IN PREGNANCY

INTRODUCTION
Embu teaching and referral hospital is a level 5 hospital located along embu-Nairobi highway,
Manyatta sub-county, Embu county.
Services that are offered in this facility include: out-patient and inpatient care services,
laboratory services , dental clinic, pediatrics, mother and child health services/ family planning
services, radiological services, maternity, theatre/surgical services, physiotherapy and chest
clinic services
I carried out this case study at the mother child health and family planning department. This is
where pregnant women and clients who have come for the clinical visits for the first time or as a
revisit, those that need immunization of pregnant mothers, physical examination and history
taking of pregnant mothers, supplementation of these of these clients and health education to
these mothers is done here. Family planning, VCT services are provided in this facility.
HISTORICAL BACKGROUND OF THE HOSPITAL
-started as a dispensary in 1924, elevated to a health a center in 1935 then to a sub-district
hospital in 1941. It had a one 30 bed ward and the first medical officer of health was posted to
the institution. Became a district hospital in 1960 and by 1984 it had a capacity of 166 beds. A
major expansion program was started by the government in 1984 to upgrade the hospital to a
provinicial general hospital. In 1985 the nyayo wards were completed(144 bed capacity). In 1987
the new kitchen and laundry were completed. In 1991 an eye unit which comprises an out-
patient, theatre and a 22 bed ward was completed. Plan international embu contributed about
50% pf the total cost of the project. In 1993 a psychiatric unit with 20 beds was completed. In
1993 an 84 cot children’s ward was completed and equipped fully in partnership with plan
international – Embu at the end of 1995 a maternity unit of 18 beds and 40 cots with an operation
theatre was completed. It was occupied on 22nd February 1996. This project was funded by plan
international embu at an approximate cost of 54million. Plan international embu also equipped
the unit fully.
VISION OF THE HOSPITAL- to be a leading health facility in the east African region by
offering quality and passionate health care that is acceptable and cost effective.
MISSION- to promote and provide quality, affordable and accessible specialized curative and
rehabilitative health care services with emphasis on professionalism, innovation and use of new
and safe technologies.
CORE VALUES- honesty, integrity and trustworthiness throughout the process of service
delivery.
- Staff initiative and involvement by creating opportunities for the people to learn and
grow.
DESCRIPTION OF THE PLACEMENT
The mother-child health/family planning department in embu level 5 hospital is divided into nine
mini-departments which include; the triage where all mothers and children under 5 years are
weighed and vital signs taken, nutritionist room and child welfare clinic room, a consultation
room where sick children and pregnant mothers having minor and major danger signs are
reviewed are reviewed by doctors. Another room is the PMTCT, immunization room, family
planning room,2 antenatal(ANC) clinic rooms. Procedures such as cervical cancer screening
done using VIA/VILLI, jadelle/Implanon removal and insertion, IUCD insertion and removal are
done in the family planning room. I was placed in the mother and child health clinic for my
reproductive health 1and 111 clinical foe 4 weeks.
CASE STUDY
BIO DATA OF THE CLIENT
Name : Jacinta Wanjiku
Age :22years
Sex: female
Residence: Embu/Majimbo
Marital status: married
Para: 0+0
Gravida: 1
Religion: Christian
Anc no;
LMP: 19/6/2022
EDD: 26/3/2023
Height :160cm
Weight: 62.1kg
DOB: 4/6/1999
Level of education: university
Occupation: hair dresser
Next of kin: dennis mwiati
Relationship: husband
Phone no: 0727143007
DX: vaginal candidiasis
CHIEF COMPLAIN
Mrs Jacinta Wanjiku , a 22 year old client, para 0+0 gravida 1, came to the antenatal clinic on
16th January 2023 with complains of lower abdominal pains, vaginal itching and presence of a
white thick discharge from her vagina
HISTORY OF THE PRESENTING ILLNESS
Mrs Jacinta came to the antenatal clinic with a history of 3 day signs of white thick discharge,
vaginal itching, and lower abdominal pains. On examination of the vagina there was
erythema(redness) and presence of a white discharge which had no foul smell and the presence
of a curd like white discharge on the walls of the vagina. She said that she had being using a
scented soap(Dettol bath soap) the she noticed that this aggrevated the symptoms. She . I and
nurse carol did a abdominal palpation: with findings of a fundal height of 32/40, gestation of
31/40, cephalic presentation and a longitudinal lie was noted, fetal heart rate and fetal
movements were present. Fetal heart rate of 136 beats per minute was also noted
Vital signs of the client
Blood pressure: 116/81mmhg
Pulse rate: 78 beats per minute
Respiratory rate:16 breaths per minute
Temperature: 36.7 degrees celcius
PAST MEDICAL HISTORY
Client has: no surgical history
No history of blood transfusion
No history of any admission to hospital
No history of any chronic illness for example: hypertension and diabetes mellitus and cancer
No history of being affected by tuberculosis
No history of any food allergies and drug alllergies
FAMILY HISTORY
She is the first born in a family of 4 children one dead and 2 alive. She is raised by a single
parent (mother). There is no history of chronic illness in the family such as cancer, hypertension,
diabetes. She is married and lives with the husband who is a business man and there is no history
of twins in the family.
OBSTETRIC AND GYNECOLOGICAL HISTORY
Menarche started at the age of 14 years and has irregular cycle and lasts for 3 days with no
menstrual disorders. Her last menstrual periods were on 19/6/2022 and her expected date of
delivery is on 26/3/2023. She has ever used emergency pills to prevent pregnancy once and a
history of jadelle implant as her method of family planning.
SOCIOECONOMIC HISTORY
She is a hair dresser and lives with her husband who is a business man. She is a Christian and
attends the African inland church of Kenya, she does not smoke, drink alcohol or abuse any
illegal drugs. She has opted to use linda mama during this period of pregnancy.
REASON FOR SELECTING THE CASE
During my placement in antenatal clinic UTIs and vaginal candidiasis were the most common
cases that affected pregnant women who were examined and diagnosed with these cases.
Vaginal candidiasis is one of commonest conditions that are affecting pregnant women. This
condition caught my attention because of the prevalence in this region and the increased number
of cases of the mothers that come to this hospital and are diagnosed with vaginal candidiasis
If left untreated, vaginal candidiasis will most likely get worse causing itching, redness and
inflammation of the area surrounding the vagina. This may lead to a skin infection if the
inflamed area becomes cracked and continual scratching creates open cuts. The complications
that affect the pregnant women with this case such as infertility if the infection goes beyond
intrigued me to choose this case.
Furthermore, I decided to chose this case since vaginal candidiasis in pregnancy affects both
fetal and maternal health and it is important for healthcare providers to provide proper health
education, nursing and medical management in order to eradicate this problem and also help
other pregnant women that come to the antenatal clinics with such a problem.

Physical examination.
HEAD
On inspection, the hair was equally distributed; clean, neat and black in color and no infestation
of parasites noted, the size of the head correspond to the body. On palpation the head had no
abnormal masses or lesions noted and the hair texture was fine. The temporal arteries had equal
pulsations of 2+ and regular.
FACE
The face was symmetrical and no drooping on one side of the face. The client was able to
express the facial expressions with ease thus facial nerve intact. No edema on the face.
EYE
On inspection, the eyes were equal in size, the eyebrows were able to move bilaterally and have
no lesions, no discharge from eyelids and eye lashes, pupils are round ,equal in size and shape.
The sclera was white and the conjunctiva was pink. The eyes are bilaterally aligned no yellowing
of the sclera.
NOSE
Color of the nose is the same as the rest of the face, there is no tenderness, no scar, the septum of
the nose is intact and no discharge from the nose.
EAR
Ears are equal in size bilaterally; auricles are aligned with the corner of each eye. Ears have no
lesions, and no discharge from the ear. On palpation there was no pain and tenderness reported.
MOUTH
On inspection, the lips were moist and pink in color with no lesions. The teeth were white in
color; the teeth were all present and no dentures seen. The gums were pink in color and no
lesions, the tongue was centrally placed and no paleness was noted and was able to move the
tongue with ease. The mouth opened symmetrically and no pain while the patient tried to open
the mouth. The range of movement while opening the mouth was normal and no pain was said
by the patient.
NECK
On inspection, the neck is symmetrical, no enlargement of the thyroid gland, the neck range of
motions of the patient was intact and no jugular vein distention present. On palpation lymph
nodes not felt, trachea is in midline and no lumps and tenderness noted.
CHEST
On inspection the size of the chest was normal, color same as other body parts. On breast
palpation no lump or tenderness felt, and patient did not report of any pain on palpation. There
was no presence of any discharge from the nipple.
ABDOMINAL
On inspection-Color was consistent with the skin color of other parts of the body, striae
gravidarum present, linea nigra present, there was no presence of any scars and the umbilicus
was midline. Abdomen was gravid and the shape was globular. Umbilicus present and midline
and inverted.
On palpation-Fundal height of 32/40, fetal movement present, longitudinal lie, cephalic
presentation and right occipital anterior position.
On auscultation-Fetal heart rates heard and regular at 136 beats per minute. The mother reported
that fetal movements were present
LOWER LIMBS
On inspection the client’s skin was intact and the skin color was normal with no cyanosis or
paleness. There was no presence of edema on the ankles and legs. No presence of interdigital
infections. The range of motion of the client’s lower extremities was strong.
I used the homan’s sign test to determine if the client was affected by deep vein
thrombosis(DVT), the client had no facial grimacing and the skin’s temperature was normal.
INVESTIGATIONS (ANC profile)
The following tests were requested for investigation in the laboratory (Urinalysis, VDRL, RBS,
HBsAG and blood sample to rule out malaria parasites), after which the results showed no
presence of Malaria parasites, the urine was turbid with a deep amber color with deposits of 8-10
pus cells, yeast cells +++ and ++ leucocytes, no protein in urine, VDRL negative, and
hemoglobin level of 13.0g/dl, blood group A, rhesus positive, RBS was 6.2mmol/hepatitis B was
negative. I carried out a retest for HIV using the dual kit since the mother was at her third
trimester and turned out to be non-reactive (NR).
Nursing care plan for Jacinta Wanjiku for 6 hours
Assessment Nursing Expected Nursing Rationale evaluation
data diagnosis outcome intervention

Patient Acute pain Patient will Identify To determine Patient

verbalizes of related to report source, the course of verbalized
pain at the body discomfort is location, and treatment and pain relief
genital area response to relieved after extent of individual after 6 hours
Facial an infective 6 hours discomfort; interventions
grimacing by agent note signs
the client evidenced by and
Restlessness patient symptoms of
of the patient verbalizing of infectious
pain on the process.
genital area
and facial Provide Helps
grimacing information promote
about dryness and
hygienic prevent skin
measures breakdown.
such as
frequent
bathing, use
of cotton
underwear
Client knowledge Client will Explain to
Frequent The client
verbalizes deficit related verbalize the client
recurrences was able to
inaccurate to lack of knowledge of about risk
may indicate verbalize
information, exposure to causes and factors, that the client knowledge
asks many accurate treatment of prevention, has no about causes,
questions information her condition and treatment
understanding treatment,
about her evidenced by and of candidiasis
of the disease management
condition and recurrent importance and its and
verbalizes candidiasis of adhering management. prevention of
recurrence of to drug Encouraged In the first recurrence of
infections regime after the client to few days of the infection
30 minutes finish all antibiotic after 15
 prescribed therapy, minutes
antibiotics, urinary
even if symptoms of
symptoms burning,
resolve. frequency,
and urgency
usually
resolve.
However, Not
finishing the
antibiotic on
the prescribed
time will
make the
bacteria grow
and multiply
again.

Teach on the Completely

client emptying the
importance bladder
of frequent prevents
bladder bladder
emptying. distention and
compromised
blood supply
to the bladder
wall. These
predispose
the client to
the infection
Taught the
client about The goal of
the client
importance teaching is to
of preventing resolve the
the infection current
infection and
prevent
recurrence.

LITERATURE REVIEW
Introduction
Candidiasis is a fungal infection caused by a yeast( a type of fungus)called candida. Some
species of candida can cause infection in people; the most common is Candida albicans. Candida
normally lives on skin and inside the body, such as the mouth, throat, gut, and vagina without
causing problems to these parts. The increased prevalence of local and systemic disease caused
by Candida species has resulted in numerous new clinical syndromes, the expression of which
depends primarily on the immune status of the host. Candida species produce a wide spectrum of
diseases, ranging from superficial mucocutaneous disease to invasive illnesses, such as
hepatosplenic candidiasis, Candida peritonitis, and systemic candidiasis. The management of
serious and life-threatening invasive candidiasis remains severely hampered by delays in
diagnosis and the lack of reliable diagnostic methods that allow detection of both fungemia and
tissue invasion by Candida species.
Candidiasis affects mainly these areas; skin, genitals, throat, mouth, blood.
Over 75% of women suffer from a C. albicans infection, usually vulvovaginal candidiasis, in
their lifetimes, and 40-50% of them will have additional occurrences. Candida albicans are the 4th
leading cause for nosocomial infections in patients bloodstreams. This could result in an
extremely life threatening systemic infection in hospital patients with a mortality rate of 30%.
Definition of candidiasis
Candidiasis is also known as moniliasis, is a fungal disease that is classified under opportunistic
fungal infection, because of its occurrence in persons with an immune-suppressed system,
especially newborns, HIV/AIDS patients, patients on antibiotic therapies and cancer therapy
patients. It usually does not cause disease in healthy individuals. It is an overgrowth in the gut by
Candida albicans species of yeast-like fungi. The yeast-like fungi mutate into a fungal form,
proliferating and invading the gastrointestinal tract and its walls, to cause candidiasis.
PATHOPHYSIOLOGY
Candidiasis is caused by abnormal growth of candida albicans which is usually due to imbalance
in the environment, more likely occurs in women vagina than in men. It can be triggered by
antibiotic use which decrease the amount of lactobacillus which decrease amount of acidic
products and pH of the vagina, pregnancy, uncontrolled diabetes, impaired immune system and
irritation of the vagina. Candidiasis albicans are able to take advantage of condition and
outcompete normal microflora hence yeast infection. The causative agent has certain virulence
factors that make it harmful to the host, use of cell wall adhesins which contains proteins hence
promoting binding of the organism to the cells of the host through hydrophobic interaction hence
reducing clearance of yeast infection in the body under normal immune regulation. When
candidiasis albicans penetrates mucosal surface there's polymorphic growth which helps yeast
invade host by secreting various degradative enzymes, moreover, phenotypic switching provides
cells with flexibility that results in the adaptation of the organism to the hostile condition.
Pregnancy and vaginal candidiasis
Pregnancy is one of the most common predisposing factors. Studies have showed that up to 60%
of pregnant women worldwide on any day can be affected. The high levels of reproductive
hormones and an increase in the vaginal environment’s glycogen content create a favorable
environment for Candida species, providing an abundant source of carbon for candida growth,
germination, and adherence. The acidity of the pregnant vaginal flora can suppress the growth of
other microorganisms that are naturally inhibitory to Candida.
Signs and symptoms of vaginal candidiasis
Pain in the vagina
Pain during sexual intercourse
Abnormal Vaginal discharge, vaginal itching, vaginal inflammation/vulval inflammation
Burning sensation when urinating
Risk factors for vaginal candidiasis in pregnancy
Wiping from back to front after using the toilet
Gestational diabetes
Immunologic alterations
Increased estrogen levels
Increased vaginal glycogen production
Recent use of antibiotics
Diabetes mellitus
Use of oral contraceptives
Lack of proper regular hygiene practices
Multiple sexual partners
Previous history of vaginal candidiasis
Classification of candidiasis
Cutaneous candidiasis affects the skin; skin pores and nails, for example, candida folliculitis,
candida, chronic mucocutaneous candidiasis, congenital cutaneous candidiasis, diaper
candidiasis, candida onychomycosis
Systemic candidiasis affects the deep-seated organs and the bloodstream, for example,
candidemia, a form of fungemia that causes sepsis, invasive candidiasis, chronic systemic
candidiasis (hepatosplenic candidiasis). It is associated with chronic administration of
corticosteroids or immune-suppressive agents, especially in persons with leukemia, lymphoma,
and aplastic anemia.
Mucosal Candidiasis affects the mucosal lining of the host such as oral candidiasis, candida
vulvovaginitis, gastrointestinal candidiasis, and respiratory candidiasis. This infection is most
common among persons who are immune-compromised including AIDS patients, pregnant
mothers, diabetes, infants and children, women on birth control pills.
DX of vaginal candidiasis
Genitourinary candidiasis - A urinalysis should be performed; evidence of white blood cells , red
blood cells, protein, and yeast cells is common, urine fungal cultures are also useful.
Medical history. This might include gathering information about past vaginal infections or
sexually transmitted infections.
Perform a pelvic exam. Examination of external genitals for signs of infection followed by
placement of speculum into the vagina to hold the vaginal walls open to examine the vagina and
cervix — the lower, narrower part of the uterus.
Test vaginal secretions. Sample of vaginal fluid for testing to determine the type of fungus
causing the yeast infection. Identifying the fungus can help prescribe more effective treatment
for recurrent yeast infections.
COMPLICATIONS AND EFFECTS OF VAGINAL CANDIDIASIS ON PREGNANCY
Low birth weight of the baby
Risk of miscarriage
Preterm birth
Post abortion endometriosis
Premature rupture of membranes

MANAGEMENT OF VAGINAL CANDIDIASIS

Clotrimazole
Mode of action
Affects the permeability of the fungal cell wall, allowing leakage of cellular contents. Not active
against bacteria. Therapeutic Effects: Inhibited growth and death of susceptible Candida, with
decrease in accompanying symptoms of vulvovaginitis (vaginal burning, itching, and discharge).
Nursing consideration
Instruct patient to apply medication as directed for full course of therapy, even if feeling better.
Advise patient to avoid using tampons while using this product.
Instruct patient on proper use of vaginal applicator. Medication should be inserted high into the
vagina at bedtime. Instruct patient to remain recumbent for at least 30 min after insertion. Advise
use of sanitary napkins to prevent staining of clothing or bedding.
Advise patient to consult health care professional regarding intercourse during therapy. Vaginal
medication may cause minor skin irritation in sexual partner. Advise patient to refrain from
sexual contact during therapy. Advise patient to report to health care professional increased skin
irritation or lack of response to therapy. A second course may be necessary if symptoms persist.
Advise patient to dispose of applicator after each use.
Ketoconazole
Mode of action
Disrupts fungal cell membrane. Interferes with fungal metabolism. Also inhibits the production
of adrenal steroids. Therapeutic Effects: Fungistatic or fungicidal action against susceptible
organisms, depending on organism and site of infection.
Nursing consideration
Instruct patient to take medication as directed, at the same time each day, even if feeling better.
Take missed doses as soon as remembered; if almost time for next dose, space missed dose and
next dose 10–12 hr. apart.
Advise patient to avoid concurrent use of alcohol while taking ketoconazole; may cause a
disulfiram-like reaction (flushing, rash, peripheral edema, nausea, headache) and increase the
risk of hepatotoxicity.
Side effects
May cause dizziness or drowsiness. Caution patient to avoid driving or other activities requiring
alertness until response to medication is known.
Fluconazole
Mode of action
Inhibits synthesis of fungal sterols, a necessary component of the cell membrane. Therapeutic
Effects: Fungistatic action against susceptible organisms. May be fungicidal in higher
concentrations
Nursing consideration
Instruct patient to take medication as directed, even if feeling better. Doses should be taken at the
same time each day. Take missed doses as soon as remembered, but not if almost time for next
dose. Do not double doses.
Instruct patient to notify health care professional if skin rash, abdominal pain, fever, or diarrhea
becomes pronounced, if signs and symptoms of liver dysfunction (unusual fatigue, anorexia,
nausea, vomiting, jaundice, dark urine, or pale stools) occur, if unusual bruising or bleeding
occur, or if no improvement is seen within a few days of therapy.
Nutritional therapy
The role of nutrition is to provide vigorous immunity against infectious diseases. Advise the
client on well-balanced diet and healthy diet that will improve the immunity of the client hence
fighting against infection, moreover, preventing the client from contracting infections.
Personal hygiene
Vaginal hygiene
Douching can an imbalance in the normal flora resulting in an overgrowth of fungi and yeast
infection. Advice the client to wipe from front to back this helps prevent the spread of yeast
between the anus and vagina.
Advised the client to avoid wearing tight fitting pants and jeans as tight clothing's leads to poor
ventilation and can accumulate moisture and provide and can provide environment for infection
Encouraged the client on getting early and regular perineal care when pregnant
CRITIQUE
During my placement at the MCH most of the health practitioners did not provide enough health
education concerning the danger signs during pregnancy, some of the minor discomforts during
pregnancy some of the conditions that may affect pregnant women. If this is done there will be
minimal cases concerning minor conditions and diseases that affect pregnant women
Commendation
I would like to thank the staff of the Medical Laboratory Services, Gynecology and General Out-
patient departments, and nurses for the support and taking part in generating clinical data from
subjects.
I commend the medical team at Embu teaching and referral Hospital for comprehensive
management of this case. All aspects of treatment were taken into account in management of this
condition.
Recommendation
I would recommend the medical practitioners in Embu teaching and referral Hospital to remain
updated so that quality care can be given to pregnant women.
Diagnosis of infection should not be made on clinical criteria only, because some time women
have another condition. All patients who have itching and vaginal discharge should be routinely
diagnosed by culture.
Proper health education program should be introduced for all pregnant women for prevention,
early diagnosis and increase awareness about importance of treatment because multiple
unreasonable miscarriage and neonatal death has been reported.
Conclusion
This study concluded that vaginal candidiasis disease is of considerable importance during
pregnancy as many pregnant women under study suffered from it. Itching, pain and whitish
vaginal discharge were the main signs and symptoms of vaginal candidiasis, but laboratory
support is necessary for a differential diagnosis or to confirm the clinical diagnosis of vaginal
candidiasis. Candida albicans is the most prevalent vaginal Candida species across all age groups
and trimesters. Although there is generally a high frequency of vaginal candidiasis, and an
increased ratio of vaginal candidiasis in third trimester which requires these women to be
routinely screened for vaginal candidiasis regardless of symptomatic status. Antifungal therapy is
one of the important tools to cure and help in eradication of vaginal candidiasis
Health care workers can help the nation to achieve national health goals. These goals speak
directly to both the fetus and the mother because pregnancy is a high-risk factor for them. Close
monitoring in pregnant women and health teaching as much as possible about pregnancy could
definitely reduce pregnancy related complications.
REFERENCES
1. http://www.webmd.com/a-to-z-guides/understanding-candidiasis-basics
2. Fraser, D, M., & Copper, M, A. (2009). Myles: Textbook for midwives (15th Ed.).
Edinburgh: Churchill Livingstone.
3. Dias, L.B.; Souza, C.; Melhem, M.; Szeszs, M.W.; Filho, J.M. and Hahn, R.C. (2011).
Vulvovaginal candidiasis in Mato Grosso, Brazil: pregnancy status, causative species and
drugs tests, Braz J Microbiol., 42(4): 1300-7.
4. https://bibliotecadigital.ipb.pt
5. https://www.researchgate.net
6. SIFAKIS, S. and PHARMAKIDES, G. (2012), candidiasis in Pregnancy. Annals of the
New York Academy of Science: 2000; 900:125-36
7. https://go.drugbank.com