Intimate Partner Violence and Sexual Assault in Pregnancy
Intimate partner violence (IPV) and sexual assault are common violent crimes perpetrated on women. Accurate statistics are difficult to obtain because these crimes are significantly underreported to both law officers and medical personnel. Sadly, pregnant women are not exempt from becoming victims of these crimes. When a woman is in a dysfunctional relationship, pregnancy may function as a stressor leading to increased episodes of violence (Jasinski, 2001). Depending on the patient population, prevalence rate estimates of physical abuse in pregnancy range widely. A recent review concurs with a likely rate of approximately 1 in 5 women (Gazmararian et al., 1996; Mendez-Figueroa, Dahlke, Vrees, & Rouse, 2013). In one trauma center, 31.5% of pregnant trauma patients suffered their injuries as a direct result of IPV (Poole et al., 1996). Obstetric (OB) complications associated with trauma include miscarriage, preterm labor, and placental abruption. IPV is not just physical in nature; it also includes behaviors such as stalking as well as verbal and psychologic aggression. Ongoing mental health issues, including depression and anxiety, are more prevalent in pregnant women subjected to any form of IPV, whether or not direct physical violence is involved. One study showed that pregnant women subjected to verbal threats were twice as likely to deliver low-birth-weight infants (Gentry & Bailey, 2014). All women who present to an OB triage unit or an emergency department (not just those who present with an injury or complication) must be screened for IPV. An organized plan for providing the victim with resources must be readily available when a screen is positive.
If a woman has sustained obvious or major trauma, it is likely the patient will first be taken to a general emergency room or a regional trauma center. The emergency room physician will stabilize the woman and likely call for an OB consultation. If a woman identifies herself as a victim of partner violence or sexual assault at the point of entry, the waiting time needs to be minimized. The victim ought to be brought immediately to a private room for evaluation. If a woman does not want to involve law enforcement, the medical provider is not obligated to report to the police unless she is considered a vulnerable person, such as a child or someone who is mentally or physically incapacitated. Mandated reporting is state specific, and therefore it is critical to know the requirements in the state where the medical provider practices.
Screening Tool for Domestic Violence
Patients are screened for domestic violence with the following questions:
• Is anyone close to you threatening or hurting you?
• Is anyone hitting, kicking, choking, or hurting you physically?
• Is anyone forcing you to do something sexually that you do not want to do?
Source: Courtesy of Women & Infants Hospital, Providence, RI.
Women who have sustained minor trauma may spontaneously present to an OB triage unit. Although complaints of preterm contractions, abdominal pain, or vaginal bleeding may raise awareness to ask specifically about trauma events, often pregnant women who have sustained IPV will not truthfully admit to the cause of trauma; they seek care only for the purpose of ascertaining fetal well-being. A woman may present to an OB triage unit and admit to the cause of trauma, with subsequent complaints of head, neck, back, or neurologic symptoms. If a normal fetal heart is found and there are no obvious signs of labor or vaginal bleeding, strong consideration can be given to transfer the woman for a complete trauma evaluation by an emergency physician. More extensive fetal evaluation can be arranged in the trauma unit or after the mother is stabilized.
When a woman presents late in gestation with little or no prenatal care, the provider must consider that she may be a victim of IPV and the partner might not have allowed her to seek prenatal care earlier. There are several IPV screening tools currently available, and most hospitals have policies for screening. An example of a quick and effective screening tool is presented in Exhibit 25.1. IPV increases the risk of anxiety, depression, and persistent substance abuse in pregnancy. A pregnant woman may be afraid to answer the screening questions honestly; therefore, IPV needs to be considered when one of these conditions is revealed or the patient’s account of trauma seems unlikely given the physical findings.
It is crucial to be able to screen the woman alone. Many times a perpetrator will exert significant control over a victim, and even when asked, the partner will not leave the room. A simple diversion may be attempted once, but if the triage staff feels threatened at any time, it is crucial to have security alerted and available. There has been a significant rise in violence perpetrated against health care workers in emergency room settings (Gates, Ross, & Mcqueen, 2006).
A complete physical is performed on all women, especially noting any bruises, lacerations, reddened areas, or evidence of bleeding. If the victim is pursuing charges against the perpetrator, photographic documentation of any findings will be helpful after obtaining consent. Emergency rooms typically have policies regarding photographing injuries, and a similar policy needs to be established in OB triage units. If the police have already photographed the victim, repeating the process will be unnecessary. A written, detailed description of any injuries can be thoroughly documented in the medical record.
299LABORATORY TESTING AND IMAGING STUDIES
In cases of physical trauma, a blood type and potentially a Kleihauer–Betke (KB) test will need to be obtained. This is a measure of fetal blood cells in the maternal circulation. If trauma and/or bleeding have occurred in an Rh-negative woman, there is a risk of fetomaternal hemorrhage with subsequent Rh D sensitization. All women with a history of trauma need to receive Rh D immunoglobulin within 72 hours of the incident, but the KB test is necessary in order to determine the correct dose of Rh D immunoglobulin. If more than 30 mL of fetomaternal hemorrhage is determined to have occurred on the basis of the KB value, then it will be necessary to administer more than the standard 300-mcg dose of Rh D immunoglobulin. A blood bank can determine the appropriate dosing, depending on the test results.
Injuries that cause tenderness and swelling can be x-rayed for evidence of fractures, and the pregnant uterus will need to be shielded. In the case of head injuries or other severe injuries, if CT is indicated, this test must be performed. A complete ultrasound examination is indicated if gestational age is unclear or there is vaginal bleeding. If a fetal nonstress test is indicated and is nonreactive, a biophysical profile is then performed to further evaluate the fetal condition.
The gestational age of the fetus must be carefully obtained. In the previable fetus, no fetal monitoring is necessary other than documentation of the fetal heart rate. It is often reassuring for the pregnant woman to see the fetus on bedside ultrasound, if available. If the woman is reporting painful contractions and is beyond 20 weeks gestation, there may be some utility in monitoring for contractions only. If regular contractions are identified, prolonged observation may be indicated to ensure discharge is not carried out prematurely. Once a viable gestation has been reached, prolonged monitoring may be indicated. Monitoring is used to assess for contractions, which will be present in cases of preterm labor or placental abruptio. A significant placental abruption may be indicated by persistent late decelerations. A nonreassuring fetal status in a viable gestation would indicate the need for emergency delivery.
Anyone who is identified as a victim of interpersonal violence must receive caring, emotional support from the medical providers working in an OB triage unit or emergency care setting. When a victim is identified, social services, behavioral health, or psychiatry are frequently helpful and can thoroughly assess a woman’s needs. A safety assessment must be performed for each victim, specifically asking if the perpetrator had a weapon, where the victim will go after release from the hospital, if there is access to a cell phone, and who will be available for support. The pregnant woman may also need assistance in obtaining shelter. Occasionally, a victim will express suicidal or homicidal ideation, which must be evaluated by a behavioral health professional.
Interpersonal violence leading to trauma of a pregnant woman is common and potentially life threatening to both the woman and the fetus. The well-being of both the mother and the fetus must be ascertained when a woman presents with a history of trauma. Often, the medical staff will suspect IPV, but the woman will deny being subjected to violence. Asking the screening questions will allow the pregnant victim to know she can turn 300to an OB triage unit if she becomes ready to reveal her secret. A checklist of information and resources needed in the event of a positive IPV screen is included in Exhibit 25.2.
Information and Checklist of Resources Needed When a Violence Screen Is Positive
1. The pregnant woman must first be medically stabilized. If there is a history of significant trauma, especially if the patient has head, neck, back, or neurologic symptoms, or mental status changes, consider consulting or transferring the patient to a trauma center.
2. Once the pregnant woman is stable, ascertain if there is any danger of the perpetrator presenting to the OB triage. Contact security or local police if there is a possibility of this happening.
3. If the patient would like to report to the police, call the police office in the town where the violent episode occurred. Do not call the police without the patient’s permission.
4. Know your state’s laws on mandated reporting, especially in the case of an adolescent. If there are questions, contact your risk management department.
5. Perform an assessment of the pregnant woman and her fetus. Thoroughly document. Consider:
Photography of bruises, lacerations, marks
X-rays or CT scans, if necessary for a complete evaluation
Fetal evaluation with ultrasound, nonstress test (NST), prolonged fetal heart monitoring, or biophysical profile as determined by fetal age
Administering tetanus vaccine or Rh immune globulin when appropriate
6. Perform a safety assessment:
Does the perpetrator have a weapon?
Does the victim have a cell phone?
Has the victim ever thought of hurting herself or others?
If the pregnant woman expresses suicidal or homicidal ideation, this is an emergency. Behavioral health or psychiatry and nursing management must be contacted and the patient needs to not be left alone.
Where will the victim go?
Maintain a list of local domestic violence advocacy centers. The National Domestic Violence Hotline can be reached at 1-800-799-7233 or on the Internet at www.ncadv.org.
Contact your hospital social worker for assistance in arranging discharge planning and shelters. A list of women’s shelters that accept pregnant patients needs to be maintained.
Does the victim have support systems?
7. Make certain the patient has access to follow-up prenatal care.
8. Make posters, cards, or brochures with local IPV resources easily available for patients in your triage unit.
IPV, intimate partner violence; OB, obstetric.