Who you are:
You are an FY 2 in OBG.Who the patient is:
Alicia Peterson, aged 32, is 26 weeks pregnant and presented to the hospital complaining of vaginal bleeding. She is here for her antenatal check-up. Your nurse colleague examined her and found no visible bleeding in her vagina.Ultrasound showed a viable 26-week pregnancy examination result was normal. Your nurse colleague noticed fingerprint-like bruise on her right wrist, but she did not disclose it to the patient.
What you should do:
Please talk to the patient, review the patient, discuss
necessary management and address her concerns.
POSITIVE FINDING
● Her voice will be quiet, looking down & not making eye contact: don’t ask her to speak up.
● Pregnancy is uncomplicated, NAD.
● Keep offering confidentiality, give pauses, show sympathy.
● If she says, she wants to go home: YOU CAN GO HOME. Ask “why are
you so anxious to go home?”
● She will open up (sometimes at 2 min bell)
APPROACH:
D: I understand that you came with bleeding from your front passage, and a scan was done, has anyone explained the findings to you?
P: Is my baby fine?
D: Let me reassure you, the scan came back normal and your baby is fine.
P: Thank you doctor, the nurse asked me to talk to you, can I go home now?
D: Yes you can go home, but before that can we have chat to make sure
everything is ok with you?
P: OK.
D: I can see that you are uncomfortable, are you ok? I understand that you had some bleeding, do you have any idea what may have caused it?
P: It happened spontaneously; I don’t know.
Offer confidentiality
D: I want to make sure you know that anything you tell is confidential between you and the medical team. We just want to make sure you are ok.
P: OK doctor.
D: One of the nurses told me that she found some bruises and burn marks on your body, can I have a look at them? May I know how you got them?
Don’t keep telling her about confidentiality, once is enough, give the patient time to speak, be sensitive.
P: I don’t want to talk about it.
D: What might happen if you talk about it?
P: He might kill me.
D: Who might? This is a safe place here. No one can harm you.
P: My husband.
D: You seem frightened of him; Can you tell me what is happening with him?
P: He has been abusing me verbally and physically for the past 2 years. He always threatens me if I ever speak about it.
D: I am really sorry about that. He can’t hurt you here. Was he the one
responsible for the bleeding?
P: Yes, he kicked me in the tummy.
D: This must be difficult for you, who do you live with?
P: We have a 3-year-old boy called Sam.
D: Has he ever hurt him?
P: No.
D: Has he ever hurt you in front of him?
P: Yes.
Do not use the word abuse when taking history ‘that’s a conclusion’
EXPLORE ABUSE:
Does he physically hurt you
Does he hit you
Does he hurt you in other ways like saying things to hurt your feelings
Push you down
Calling you names
Physical + verbal + psychological + sexual
Do not ask about sexual abuse
Does he force himself on you - if you had to ask
How long has this been going on
SUPPORT
D: Have you tried to discuss this to anyone?
P: No.
D: What about any family or friends?
P: He prevents me from visiting anyone.
IMPACT
D: How is your mood?
P: It’s ok.
D: On a scale from 1 to 10, with being the lowest and 10 being highest, can you grade your mood?
P: 4.
D: Sometimes when someone is going through a difficult time, they may have thoughts of hurting themselves, is that the case with you?
P: No.
D: How do you cope with all of this stress?
P: I just try to take care of my child.
D: I really appreciate that, you are a lovely and caring mother.
Husband:
D: What does your husband do for a living?
P: He is an accountant.
D: How long have you been together?
P: 5 years.
D: Does he drink alcohol?
P: Yes, 4 glasses of whiskey a day for the last 3 years.
D: What about smoking?
P: No.
D: Any recreational drugs?
P: No.
D: Does he has any financial problems?
P: No.
D: Does he have a criminal record?
P: No.
EXAMINATION:
● My nurse colleague examines you and found a bruise on your wrist, may I examine you too please?
● I would like to check your observations, do a general physical
examination and check your wrist: fingerprint bruise on the wrist.
Explain
I am really sorry to hear about what you are going through. Domestic violence is something taken quite seriously by the police. It’s a criminal offence and you don’t deserve this, and you are being very brave by talking about it, I know it wasn’t easy for you.
MANAGEMENT
- Offer support This is completely illegal you do not need to put up with
this. - Offer talking therapy
- We would like to keep you in the hospital for a while to make sure
everything is fine with you. - Call my senior to review your case, he has better experience with these
kinds of situations. - Involve social services
There is a designated person in the hospital who deals with these issues we can arrange a meeting with that person he will explain about the services available to support you and your child. I know that your husband is not aggressive to Sam but witnessing what is happening to you can affect him emotionally and psychologically also. - Involve the police.
- Tell her about the national Domestic helpline number
- Direct her to someone who can offer her financial support
- Support by woman’s aid group
- Refer to a sexual assault centre (SARCs)