What is the best course of action for a pregnant woman presenting to the Emergency Room (ER) with bruises and multiple signs of physical abuse, who expresses a desire to leave the hospital but is afraid to do so due to concerns for her safety?

Management of Pregnant Woman with Abuse Presenting to Emergency Room

You should immediately connect her with social work services and domestic violence advocacy resources while ensuring her safety before discharge, rather than directly notifying police without her consent. 1

Immediate Clinical Actions

Safety Assessment and Documentation

• Conduct a thorough physical examination and carefully document all injuries with precise descriptions of bruise patterns, locations, and characteristics. 1, 2
• Photograph all visible injuries, as this documentation may be critical for future legal proceedings and bruise appearance changes rapidly. 3, 2
• Assess for any injuries requiring immediate medical intervention, including abdominal trauma that could affect the pregnancy. 2, 4
• Perform fetal assessment if gestational age is ≥23 weeks, including fetal heart rate monitoring for at least 4 hours. 2

Screening and Assessment Protocol

• Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence using validated screening tools. 2
• The U.S. Preventive Services Task Force recommends screening all women of childbearing age for intimate partner violence (IPV), with screening occurring throughout pregnancy. 1
• Assessment should include evaluation of social risk factors such as mental health problems, domestic violence/intimate partner violence, social service involvement, law enforcement involvement, and substance abuse. 1

Critical Decision Point: Police Notification vs. Support Services

Why Support Services First (Option B is Preferred)

The primary approach should be connecting the patient with national family services and domestic violence advocacy rather than unilateral police notification. Here's why:

• Screening alone without appropriate intervention and patient autonomy can be harmful. 1
• The American Congress of Obstetricians and Gynecologists and other major organizations emphasize that physicians should be prepared to respond appropriately and refer patients to available community resources. 1
• Interventions that include education, advocacy, and community referral sessions have been proven effective in increasing safety-seeking behaviors in pregnant women experiencing abuse. 5
• Research demonstrates that pregnant women who received intervention protocols including information about safety behaviors showed significant increases in safety behavior adoption during and after pregnancy. 5

When Police Notification May Be Appropriate

• If there are mandatory reporting requirements in your jurisdiction for certain types of injuries or if the patient is in immediate danger and unable to protect herself. 2
• If the patient explicitly requests police involvement. 1
• If there are concerns about child abuse (if other children are in the home), which may trigger mandatory reporting obligations. 1

Comprehensive Intervention Protocol

Immediate Support Services

• Activate social work consultation immediately while the patient is still in the emergency department. 1
• Provide information on local domestic violence shelters, hotlines, and advocacy services. 5
• Offer at least one education and advocacy session that includes information on safety behaviors before discharge. 5
• Help the patient develop a safety plan that addresses her specific concerns about leaving the hospital. 5

Safety Planning Components

• Discuss safe places she can go if she needs to leave quickly. 5
• Provide information about obtaining protective orders. 1
• Ensure she has access to emergency contact numbers that she can safely store. 5
• Address her specific fear about leaving the hospital by exploring what resources would make her feel safer. 5

Medical Follow-Up

• Schedule close obstetric follow-up, as this provides ongoing opportunities for reassessment and intervention. 1, 2
• Document that fetal well-being should be carefully recorded in cases involving violence, especially for legal purposes. 2
• Consider admission for observation if there are any concerning findings such as uterine tenderness, abdominal pain, vaginal bleeding, or abnormal fetal heart rate patterns. 2

Critical Pitfalls to Avoid

• Never notify police without the patient's consent unless legally mandated, as this can escalate danger and violate patient autonomy. 1
• Do not discharge the patient without connecting her to support services, as this represents a missed opportunity for life-saving intervention. 1, 5
• Do not focus solely on physical injuries while ignoring the underlying violence, as abusive injuries during pregnancy are precursors to more severe forms of abuse including fatal outcomes. 1
• Avoid dismissing her fears about leaving as irrational—these fears are often based on accurate assessment of danger. 5

Evidence for This Approach

The evidence strongly supports intervention protocols over immediate police notification:

• A prospective study of 132 pregnant women experiencing abuse showed that intervention protocols with education, advocacy, and community referral resulted in significant increases in safety behavior adoption (p < 0.0001). 5
• The U.S. Preventive Services Task Force found that effective interventions consist of counseling that emphasizes safety behaviors and information on community resources, with one good-quality trial showing significantly fewer episodes of IPV during pregnancy and postpartum in the intervention group. 1
• Screening without appropriate follow-up intervention has not been shown to improve outcomes, emphasizing the critical importance of connecting patients to support services rather than simply reporting to authorities. 1