Adelaide Nursing School: NICS PBL Worksheet - Pregnancy Session Review

This assignment analyzes a Problem-Based Learning (PBL) session focusing on a complicated pregnancy case involving intrauterine growth restriction in twins. The student identifies key insights, such as the importance of customized dietary plans and monitoring fetal heart rates to improve patient outcomes and reduce risks. The assignment also explores critical factors affecting patient success, including cholestasis of pregnancy and subchorionic hematoma. The student evaluates the logical clinical sense of the interventions, suggests improvements, and addresses professional concerns within a multidisciplinary team context, emphasizing the need for adequate staffing and preparedness for complex pregnancy scenarios. The student also provides suggestions to improve future PBL experiences by incorporating varied scenarios based on different medical decisions.

NICS PBL worksheet
PBL Session: Pregnancy
What was one insight you learned from this PBL session? How does
this insight contribute to quality patient care?
Answer) The pregnancy mentioned in the PBL session is a complicated pregnancy case,
where one of the identical twins is underdeveloped. This condition is called the intrauterine
growth restriction. If this condition is seen in twins, one of the foetuses, tend to not acquire the
necessary oxygen and nutrients needed for the efficient growth and development of their
organs, tissues, or due to any infection. The lack of blood flow into the placenta might result in
limited amount of oxygen reaching the foetus. This can cause the foetal heart rate to decrease,
risking the baby’s life (Puccio et al., 2014). Thus, it is crucial to study her condition well and
prepare a customised diet plan mainly consisting of fresh fruits, vegetables, fish and nuts along
with foods having high folic acid concentrations and vitamin supplements, to help the
undernourished twin receive proper nutrients in order for it grow properly inside the womb.
This might be able to avoid premature delivery of the baby and might limit several
complications that the baby might acquire due to its slow development. This would thus also
help improve patient outcome, as this might ensure the reduction in the life risk of twin B and
also reduce pregnancy complications for the mother.

Patients are often complicated. Describe 3 of the major factors identified
in this case which will determine the success of this patient's outcome?
This could include medical diagnoses or nursing diagnoses.
Answer) 3 major factors:
 The patient during her pregnancy had experienced intense itchiness. So the nurses ordered blood
tests which depicted that there is an increase in the bile salt concentration in the blood, which
indicated that she was suffering from cholestasis of pregnancy (Geenes et al., 2014). Thus, the
nurses prescribed Ursodiol to the patient and recommended her to take cool baths, apply certain
creams on the itches.
 After understanding and identifying the complications of the pregnancy, the development of the
foetuses and the condition of their heart rates, were constantly monitored, with the help of
ultrasounds.
 She was also diagnosed with sub chorionic hematoma, which created a mass of blood on the
wall of the placenta of Twin A. Thus, frequent ultrasounds were performed to keep a check on
the development of the hematoma, and the patient was recommended to restrict her movement.
Given the interventions designed by your group, do you feel every
decision was underpinned by logical clinical sense?
Answer) Every decision till the decision to manually break the water to help her push out Twin A,
during a practice session, could be considered as logical. The water could have been broken after the
patient was provided with a practice session. It can also be said that the patient, being the mother of two,
did not require the practice session. Another drawback of the session would be the lack of healthcare
providers and nurses during the whole ordeal. Also, there was a delay in the clamping and cutting of the
cord, because of which twin A had to be taken for observation of any complications because of it.

Was there anything you think should have been designed differently?
Answer) The patient, being the mother of two, did not require the practice session. The main
drawback of the session would be the lack of healthcare providers and maternity nurses during the
whole ordeal. The patient should have been able to deliver the baby safely and the clamping and
cutting of the cord should have been done on time, to avoid any added complications due to it.
Was there anything brought up by another group which you missed and
would have contributed to your group discussion?
Answer) If this was a planned pregnancy, Louise should have been warned about complications she
might have faced, given her medical history. If this was an unplanned pregnancy, she should have
been educated about the use of contraceptives and other means of protections.
She after being admitted should have been kept in close observation in order to be able to help with
the pregnancy.
When considering working in a multidisciplinary team on this case,
were there areas of professional concern, which could have been
addressed at the staff level?
Answer) during the practice session there were lack of maternity nurses and other healthcare
providers who could have aided Louise during the accidental delivery of her first twin. This issue
alone should have raised some professional concern among the staff that was already present there.
They should always be ready for such cases, especially in cases of complicated pregnancies, which

are usually very unpredictable.
Please add any suggestions you may have to help us continue to
improve the PBL experience
The real world problems help us understand different complicated scenarios better and how
to implement our practical knowledge and understanding, without actually needing to
perform the task. The only suggestion that I would like to mention is to incorporate different
scenarios of this case, depending on the different decisions made for a single problem in each
of the steps of the medial procedures. This will help understand why one decision is right and
the other is wrong. This will help understand the different issues that can happen during
pregnancies as well as understand the different medications of diet plans or simple remedies
to ease the pain of the patient, in order to improve patient care.

References
Geenes, V., Chappell, L., Seed, P., Steer, P., Knight, M. and Williamson, C. (2014).
Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy
outcomes: A prospective population-based case-control study. Hepatology, 59(4), pp.1482-
1491.
Puccio, G., Giuffré, M., Piccione, M., Piro, E., Malerba, V. and Corsello, G. (2014).
Intrauterine growth pattern and birthweight discordance in twin pregnancies: a retrospective
study. Italian Journal of Pediatrics, 40(1).