DOMESTIC ABUSE IN PREGNANT LADY.

Alicial Greenway

28 years, Female

Role-play cases simulate real clinical practice to guide how candidates respond to clinical scenarios and real life practice.

Name: Alicia Greenway
Gender: Female
Age: 28 years

Background: Alicia is 28 years old and 24 weeks pregnant. She has been living with her partner, Mark, for five years. They have a four-year-old daughter (Matilda) together. Alicia came to the clinic for her daughter's vaccination, and during the visit, a nurse noticed that she had a small limp when walking and a bruise on her arm. Alicia reluctantly shared with the nurse that her partner, Mark, had grabbed her by the arm during a fight that morning. The nurse advised her to wait and see the doctor for further advice and reassurance. Alicia declined saying she had errands to run but accepted to speak to the doctor on the telephone.

Opening Line:
"In a concerned voice: 'I'm really worried about my baby and not sure what to do next.'"

Only When asked:

Mark is currently at work and you feel it is ok to talk. Matilda is asleep at the moment.
Mark has always has a temper and it gets worse when he stressed with work. It has become worse in the last 6 months. You feel like you are walking around eggshells when he is around. You have tried to be nicer and do everything he wants to avoid having any quarrels.
Mark hits you when he is angry, it happens nearly weekly, you have been able to cover up the bruised, but this morning he push shoved you into the cupboard, you fell and bumped you left hip and tummy. You did not lose consciousness or bump your head, no vomiting or any usual general symptoms.
You noticed some vaginal bleeding after the incident, there was mild tummy pain, you do not feel it is serious and you are waiting for it to pass. you can still feel the baby kick as usual.
You have some bruises and fingerprint marks on you right wrist, it does not hurt anymore. You are able to move your wrist ok, no swelling.
Support System: Has not discussed the domestic violence with family or friends.You are a stay at home mum, have very few friends because Mark does not like them, you feel out with your sister because Mark said she rude, you barely talk to your parents. You have one friend who only comes visit when Mark is not hope.
You do not work, and have to wait for Mark to give you money.
You do not smoke or drink alcohol
About your pregnancy: pregnacy is unplanned but accepted. You had missed your depo contraception. You are not sure how Mark feels about the pregnancy, you never asked him. You have registered for ANC, got your pregnancy pack, taking your medications, had your regualr scans which was ok (baby boy), you know what to do if unwell, you are not sure about healthy foods to eat or foods to avoid when pregnant.
You feel Mark will be very angry if he finds out, it would make things worse at home.
Matilda does not witness the altercation, she has not be abused in any way.
Relationship with Mark: He is 36 years old, works as a project manager, his work is very stressful, he sometimes get calls in the middle of the night, he has insomnia becuase of work, poor sleep makes things worse, he does not smoke or drink alcohol. He has a stable job but the income is low and money has been a challenge, especially with new baby on the way. You describe your relationship with Mark as strained, particularly due to his recent physical aggression. You feel that he loves you.

Physical Health: No significant health issues apart from current pregnancy

Living Situation: Alicia lives with her partner, Mark, and their four-year-old daughter. No pets.

Ideas, Concerns, Expectations:

Ideas: Alicia believes the bleeding could be related to the physical altercation or her overall stress. You believe Mark is just very stressed because of worl
Concerns: She is deeply worried about the well-being of her unborn baby and the safety of her living situation. You also do not want Mark to find out.
Expectations: You want reassurance about her baby's health and guidance on what steps to take next regarding her safety and the safety of her children.

Lifestyle:

Alicia is irregular with her antenatal clinic visits and does not recall the date of her last ultrasound. She missed her ANC because she was embarrased about brusing.
She does not mention any significant health issues apart from her current pregnancy and the recent bleeding.
She has a four-year-old daughter who is reportedly fine.

Behavior:

Alicia is anxious and worried about her pregnancy. She is reluctant at first to discuss but admits to the physical altercation with her partner.
If the doctor approaches her with empathy and support, she may open up more about her situation.
She is unlikely to seek help or disclose further details unless she feels safe and understood.
You will readily accept any advise the doctor gives.

You are a doctor in your routine clinic, ready to begin your day of consultations. A patient has been booked to see you,

Name: Alicia Greenway
Gender: Female
Age: 32 years

PMH: No chronic illness.
Current Medical History

Gravida 1 Para 1; single live delivery, SVD, healthy baby girl 4 years ago.
Registered for ANC 11 weeks ago, GA = 24 weeks, missed ANC appointment x 1.

Today
Clinical entry by ANP: Presented to imms clinic with 4years old Matilda. Maltida is well and looks fine today. Noticed Alicia limped into the consulting room and when asked, disclosed an altercation with her partner this morning. Was upset, she wasnt sure what to do. Empathized, encouraged to speak to doctor asap. Declined, insisted that she has to return home, errands to do. Booked urgent telephone with duty doctor
Plan: Urgent telephone call with duty doctor today

Marking Scheme

Data Gathering and Diagnosis

History Taking: Reviews Alicia's pregnancy status, including gestational age (24 weeks) and any complications.
Enquires about the incident leading to the bruises and the limp.
Asks about the frequency, severity, and specifics of domestic abuse incidents.
Reviews Alicia's medical history, including previous antenatal visits and any past incidents of abuse.
Establishes the timeline and context of the current situation, including the events leading up to her coming to the clinic.

Current Symptoms and Condition: Enquires about current symptoms (bleeding, pain, limp) and their onset.
Assesses her overall physical health and well-being, including any immediate medical needs.

Social and Emotional Context: Asks about her living situation and support system.
Explores her feelings and concerns about her relationship with Mark.
Enquires about her support network and any prior discussions about the abuse with friends or family.

Scoring:

Clear Pass: Comprehensive history, sensitive questioning, thorough exploration of current symptoms and social context.
Pass: Adequate history, appropriate questioning, good understanding of current symptoms and social context.
Fail: Incomplete history, inadequate questioning, poor understanding of current symptoms or social context.
Clear Fail: Missing key elements, insensitive questioning, lack of understanding of the situation.

Clinical Management and Medical Complexity

Immediate Medical Care: Provides appropriate medical evaluation for the bleeding and bruises.
Ensures the well-being of the unborn child through necessary examinations and tests.

Safety and Risk Management: Conducts a thorough risk assessment for Alicia and her children.
Discusses options for immediate safety, including potential shelter or safe housing.

Referral and Support: Refers Alicia to domestic violence support services and social workers, such as Independent Domestic Violence Advisors (IVDA), MARAC, SafeLives DASH, HARBOUR, Women’s Aid.
Provides information on legal rights and options for protection orders.
Arranges follow-up appointments for ongoing support and monitoring.

Health Education and Support: Educates Alicia about the impact of domestic abuse on her health and her children.
Discusses the importance of a safety plan and provides guidance on creating one.

Documentation and Coordination: Documents all findings, plans, and referrals accurately.
Coordinates care with a multidisciplinary team, ensuring all professionals involved are informed.

Scoring:

Clear Pass: Comprehensive management plan, appropriate referrals, thorough safety planning, excellent coordination and documentation.
Pass: Good management plan, adequate referrals, effective safety planning, good coordination and documentation.
Fail: Incomplete management plan, inadequate referrals, poor safety planning, poor coordination or documentation.
Clear Fail: Missing key management elements, no referrals, no safety planning, lack of coordination and documentation.

Interpersonal Skills / Relating to Others

Empathy and Support:Shows empathy and understanding of Alicia's situation.
Uses non-judgmental and supportive language.
Acknowledges her fears and concerns, providing reassurance.

Communication Skills:Ensures clear and sensitive communication, avoiding medical jargon.
Explains the importance of addressing domestic abuse and the resources available.
Encourages Alicia to speak openly, providing a safe space for her to share.

Building Trust and Rapport:Builds trust through active listening and validating Alicia's feelings.
Maintains confidentiality and reassures Alicia about the discretion of the consultation.
Demonstrates a patient-centered approach, respecting her autonomy and decisions.

Scoring:

Clear Pass: Excellent empathy, clear and sensitive communication, strong rapport and trust-building.
Pass: Good empathy, clear communication, effective rapport and trust-building.
Fail: Insufficient empathy, unclear communication, poor rapport and trust-building.
Clear Fail: Lack of empathy, insensitive communication, no rapport or trust-building.

These are the key issues in this clinical scenario.

Immediate Safety and Risk Assessment: Assess the immediate risk to Alicia and her unborn child, as well as her three-year-old daughter.
Determine the level of danger she faces from her partner, Mark, and whether there is an urgent need for intervention.

Medical Evaluation: Evaluate Alicia's physical condition, especially in light of the reported vaginal bleeding and the bruises on her arm.
Ensure the health and well-being of her unborn baby through appropriate medical examinations and possibly an ultrasound.

Emotional Support and Empathy: Provide emotional support and reassurance to Alicia, acknowledging her fears and concerns.
Create a safe and non-judgmental environment for her to discuss her situation more openly.

Legal and Social Support: Inform Alicia of her legal rights and options regarding domestic abuse.
Discuss available resources, including shelters, counseling services, and domestic violence hotlines.
Facilitate contact with social services or domestic violence support organizations.

Safety Planning: Develop a safety plan with Alicia, outlining steps she can take to protect herself and her children if the situation escalates.
Discuss options for emergency housing and support networks.

Follow-Up Care: Schedule regular follow-up appointments to monitor her physical and emotional health.
Ensure continuous support through referrals to appropriate healthcare and social services.

Confidentiality and Trust: Maintain confidentiality while discussing sensitive issues related to domestic abuse.
Build trust with Alicia to encourage her to share more details and seek help willingly.

Education and Awareness: Educate Alicia about the impacts of domestic violence on her health and the health of her children.
Provide information on recognizing abuse and understanding that it is not her fault.

Documentation: Document all findings, including injuries and statements, accurately and thoroughly in her medical records.
Record any plans and referrals made during the consultation.

Coordination with Multidisciplinary Teams: Work closely with a multidisciplinary team, including social workers, mental health professionals, and legal advisors, to provide comprehensive care for Alicia.
Ensure all team members are informed and involved in the care plan.

1.NICE/CKS: https://cks.nice.org.uk/topics/domestic-abuse/management/managing-domestic-abuse/

2.Lecture: PLAB Guide Academy: https://youtu.be/uWX71AFBvM0?si=AD92Qk9jaF6JSkOv

3.Lecture: Domestic violence https://www.youtube.com/watch?v=qlVwbylrPUw

4. Watch These Video (Not RCGP format/perfect, but great learning points!)

Think: What was done well?
What could be better?
Identify the cues given.
Listen to the tactics and phrases used in starting the conversation

• Domestic Violence Screening for Healthcare Professionals: Reluctant Disclosure https://youtu.be/qdJFDUj0ErE?si=Raz39gdHo5_IOzDq

• DV Screening for Healthcare Professionals: Upfront Disclosure
https://www.youtube.com/watch?v=E6y3qCx4-V4

• Teen Domestic Violence https://youtu.be/0bFB0ms5gbI?si=0c5Ojwl-eaWGGCcz

Domestic violence in a pregnant lady: https://youtu.be/vW-kizSigzI?si=DdAFoSWPg6bzHmc

Consultation Template for Addressing Alicia's Case

Data Gathering and Diagnosis

History Taking:Confirm Alicia's pregnancy status and gestational age (24 weeks).
Enquire about the specific incident leading to the bruises and limp.
Explore the frequency, severity, and context of domestic abuse.
Review medical history, previous antenatal visits, and any past abuse incidents.
Establish a clear timeline and context of the current situation.

Current Symptoms and Condition:Ask about current symptoms (bleeding, pain, limp) and their onset.
Assess overall physical health and well-being.

Social and Emotional Context:Ask about living situation and support system.
Explore feelings and concerns about the relationship with Mark.
Enquire about the support network and prior discussions about abuse.

Clinical Management and Medical Complexity

Immediate Medical Care:Provide appropriate medical evaluation for bleeding and bruises.
Ensure the well-being of the unborn child through necessary examinations and tests.

Safety and Risk Management:Conduct a thorough risk assessment for Alicia and her children.
Discuss options for immediate safety, including potential shelter or safe housing.

Referral and Support:Refer Alicia to domestic violence support services and social workers.
Provide information on legal rights and options for protection orders.
Arrange follow-up appointments for ongoing support and monitoring.

Health Education and Support:Educate Alicia about the impact of domestic abuse on her health and her children.
Discuss the importance of a safety plan and provide guidance on creating one.

Documentation and Coordination:Document all findings, plans, and referrals accurately.
Coordinate care with a multidisciplinary team, ensuring all professionals involved are informed.

This structured approach ensures comprehensive care for Alicia, addressing her immediate medical needs, safety concerns, and emotional well-being, while fostering a supportive and empathetic environment.

Interpersonal Skills / Relating to Others
Empathy and Support

Show empathy and understanding of Alicia's situation:

"I'm really sorry to hear about what you're going through, Alicia. It sounds incredibly difficult."
"I can see that this situation is very stressful for you."

Use non-judgmental and supportive language:

"Please know that you are in a safe space here, and we're here to support you without any judgment."
"Your feelings and experiences are valid, and it's important that we address them together."

Acknowledge her fears and concerns, providing reassurance:

"It's completely understandable to feel worried about your baby's health given the circumstances."
"We will do everything we can to ensure both your safety and your baby's well-being."

Communication Skills

Ensure clear and sensitive communication, avoiding medical jargon:

"Let's talk about what's been happening in a way that's clear and easy to understand."
"I'll explain everything step-by-step so you feel comfortable with the information."

Explain the importance of addressing domestic abuse and the resources available:

"Addressing any form of domestic abuse is crucial for your safety and health, and there are resources available to help you."
"We can connect you with services that offer support and protection if that's something you feel ready to explore."

Encourage Alicia to speak openly, providing a safe space for her to share:

"Please feel free to share anything that's on your mind. This is a confidential and safe environment."
"Your thoughts and feelings are important, and we're here to listen and support you."

Building Trust and Rapport

Build trust through active listening and validating Alicia's feelings:

"I hear you, Alicia, and your concerns are important. Let's work through them together."
"It's okay to feel the way you do. I'm here to help you navigate this situation."

Maintain confidentiality and reassure Alicia about the discretion of the consultation:

"Everything you share with me stays confidential. Your privacy is very important to us."
"You can trust that this conversation is just between us, and we will respect your wishes."

Demonstrate a patient-centered approach, respecting her autonomy and decisions

"It's important that you make the decisions that feel right for you. We're here to provide support and information."
"Your choices are yours to make, and we'll support you in whatever you decide."

Using these phrases, doctors can create a supportive, empathetic, and trust-building environment for Alicia, ensuring that her needs and concerns are addressed with sensitivity and respect.

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