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Screening for domestic violence during pregnancy
ORIGINAL ARTICLES
Screening for Domestic Violence During Pregnancy Elizabeth E. Saunders, RN, CEN, EMT-P Domestic violence is an international social issue and significant cause of trauma. Pregnant women are at risk for intentional trauma and pose unique challenges for care. Patients are often not truthful about the mechanism of injury and are reluctant to seek care. Prenatal and postpartum care can be adversely affected if the woman continues in the abusive relationship. A careful approach to screening all pregnant trauma patients is presented to help clinicians with assessment for intentional trauma. (Int J Trauma Nurs 2000;6:44-7.)
omestic violence is a tragic cause of worldwide trauma. It has no boundaries; it has been reported in all cultures, races, ages, sexes, educational levels, and socioeconomic groups, and is especially tragic when the victim is a pregnant woman. A US study of 1103 African American, Hispanic, and white urban female patients concluded that 1 in 5 teens and 1 in 6 adult women in the study had experienced abuse during their pregnancy.1 Internationally, a study of more than 400 villages and 7 hospitals in 3 districts of Maharastra, India, revealed that 16% of all deaths during pregnancy were a result of domestic violence and that domestic violence was the second largest cause of deaths in pregnancy.2,3 Around the world, as many as 1 in every 4 women is physically or sexually abused during pregnancy, usually by her partner.2 For the purpose of this discussion, it will be assumed that the abuser is a man, although a woman may also be the perpetrator. Pregnancy often marks the initiation or escalation of violence for women. Pregnancy may be viewed as a time of vulnerability, and for some
D
Elizabeth E. Saunders, RN, CEN, EMT-P, is a Clinical Nurse III, Emergency Department, at Sound Shore Medical Center of Westchester, New Rochelle, New York. Please write [email protected] with comments. Reprint requests: Elizabeth E. Saunders, RN, CEN, EMT-P, 125 North Dr, Staten Island, NY 10305. Copyright © 2000 by the Emergency Nurses Association. 1075-4210/2000/$12.00 + 0 65/1/106858 doi:10.1067/mtn.2000.106858 44 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Saunders
women it marks the loss of financial or emotional autonomy. The physical, emotional, and financial changes associated with pregnancy can be seen as an opportunity for an abusive partner to establish power and control over the woman. Whatever the cause, abuse during pregnancy is responsible for
Pregnancy often marks the initiation or escalation of violence for women. injuries, adverse birth outcomes, and death. Trauma care providers need to be aware of the signs and symptoms indicative of possible abuse and screen patients to find, educate, and discuss resources, as well as offer referrals. The pregnant patient must then be allowed the autonomy to opt for the services that she feels are safe for her and her fetus. SCREENING FOR DOMESTIC VIOLENCE IN THE TRAUMA CARE SETTING Table 1 provides a list of recommendations for how to conduct a routine screening of patients for domestic violence.
Medical and social history Trauma care begins with the assessment and stabilization of physical injuries. When possible, a detailed medical, obstetrical, and social history should be obtained in private. A confidential screening for domestic violence will help VOLUME 6, NUMBER 2
providers to identify social and physical problems that can affect the outcome of the resuscitation phase of trauma care and pregnancy. Women who are enmeshed in a cycle of domestic violence may have sporadic, delayed, or no prenatal care, be homeless, or have a history of substance abuse and poor nutrition. The patient should be asked about current and past abuse, previous obstetrical complications, outcomes of previous pregnancies, and the birth weights of infants. Pregnant women who are victims of violence are 4 times more likely to give birth to low birth weight neonates4 (<2500 g or 5.5 lb)5 than those who are not victims of violence. The nurse should be attentive for social cues of a patient’s potentially abusive home life. Victims of abuse do not always have the ability to leave their living situation, access to transportation, or use of telephones. They may not have the means to obtain immediate medical treatment and may only seek out medical care after they or the fetus is in distress. Isolation is a common tactic used by the abuser to maintain control, and the abused women may delay acute treatment to avoid discovery of the abuse. If the patient is suspected to be a victim of domestic violence, the nurse can ask “what if” questions to help determine how the woman’s partner “typically” reacts to various situations. Research suggests that an abuser tends to feel jealous, angry, or insecure.6 The partner may feel abandoned and jealous of the woman receiving
The enlarged gravid abdomen is a frequent target during an assault because the batterer intends to harm the fetus.
attention from family, friends, and health professionals. He may feel threatened by the loss of control when the woman seeks prenatal care or treatment for injuries.7 An insecure partner may place an emphasis on the mate’s physical appearance and dislike the outward appearance caused by pregnancy.7 There may be resentment toward the woman for the added responsibility of her pregnancy and the birth of a child.7 Table 2 lists methods used by an abuser to maintain emotional control over a victim of domestic violence. APRIL-JUNE 2000
Table 1. Recommendations for conducting routine screening for domestic violence • All pregnant women regardless of age should be routinely screened at each prenatal visit and emergency department visit. • Pregnant women in lesbian relationships should be screened for domestic violence. • Screening should be done in woman’s primary language with an interpreter who is not a friend or family member. • Pregnant women should be screened for prior incidents of domestic violence. • Trauma care providers should be aware of cultural issues and factors that influence a woman’s perception of abuse. • Screenings should be done face-to-face when the patient is alone and in a confidential, private setting. • Patients should be asked straightforward questions and asked to provide a medical and social history. • The trauma care provider should be nonjudgmental to maintain communication with the patient. From “Screening for Domestic Violence in the Emergency Department/Urgent Care, OB/GYN, and Family Planning Setting.”12
Mechanism of injury Intentional injuries are often the result of the victim being pushed, shoved, choked, kicked, punched, beaten, shot, stabbed, bitten, or burned. The woman often attempts to hide the true mechanism of injury in an attempt to protect the abuser and avoid greater reprisal. Trauma care providers should compare the pattern of injury with the reported mechanism. For example, a pregnant woman tends to fall backward, landing on her back and buttocks.8 Isolated soft tissue injuries to the neck, face, or anterior abdomen that are attributed to a fall should raise suspicion. The enlarged gravid abdomen is a frequent target during an assault because the batterer intends to harm the fetus.7 Abdominal injuries that are a result of blunt or penetrating trauma can cause life-threatening complications for the mother and fetus. The most common type of penetrating injury seen during pregnancy is a gunshot wound.8 Stab wounds are not as common and tend to have a better prognosis for the mother and fetus.9
Physical assessment Soft tissue injuries that are in multiple stages of healing on the neck, breasts, abdomen, and geniINTERNATIONAL JOURNAL OF TRAUMA NURSING/Saunders 45
Table 2. Methods used by an abuser to maintain emotional control of a victim of domestic violence Method Isolation
Economic control
Examples 1. Preventing or prohibiting prenatal care visits or access to health care 2. Denying access to family or friends 3. Denying access to transportation 4. Denying access to telephone or mail communication 1. Withholding money 2. Taking woman’s earnings 3. Not permitting woman to work outside of home 4. Making statements such as “How will you support the baby without me?”
Destruction of property
1. Destroying toys, gifts, clothing set aside for birth; newly decorated nursery 2. Destroying mother’s personal, precious items
Emotional withholding
1. Not expressing feelings related to the pregnancy 2. Ignoring the needs of the pregnant woman 3. Denying paternity
talia are highly suspicious for intentional abuse. Wounds to the hands, outer aspects of arms, or anterior surface of legs are characteristic of a woman trying to defend herself. Certain injuries are indicative of the victim being dragged (eg, loss of hair or bald patches) or restrained (eg, abrasions or bruises of the extremities, fingernail marks to the throat). If the patient was manually strangled, petechial hemorrhages may be seen in the conjunctiva, or the victim may have bitten her tongue.10 The patient may have bites or cigarette burns to the breasts. Blunt and penetrating force can result in maternal hemorrhage; rupture of the uterus, liver, spleen, or amniotic membranes; premature labor; shock; or death of the mother or fetus. The fetus may have generalized hemorrhage, fractures, intracranial hemorrhage, or intrauterine growth retardation. Depending on the stage of gestation, spontaneous abortion, placental hypoperfusion, hypoxia, 46
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Saunders
preterm delivery, low birth weight, or stillbirth may occur. Abuse to the genitalia can produce abrasions, lacerations, or hematomas of the labia or vagina.
Emotional assessment It is not uncommon for victims to experience severe stress from an abuser who uses methods to maintain emotional control (Table 1). Stress decreases the woman’s ability to obtain adequate nutrition, rest, exercise, and medical care and can be a factor in depression and suicide attempts. Abused women may use ineffective coping mechanisms, such as drug, alcohol, and nicotine abuse. Physiologically, prolonged stress causes the release of maternal catecholamines that can result in placental hypoperfusion and preterm delivery.11 FOLLOW-UP CARE FOR VICTIMS OF DOMESTIC VIOLENCE Good trauma care for a victim of domestic violence does not stop with treating the physical wounds. An abused pregnant woman and her fetus will remain in danger as long as they stay in a relationship that has potential for additional harm. If there is evidence of intentional trauma, the patient’s long-term care will be determined by individual physical and social needs, hospital protocols, and state law. Although a full discussion of that care is beyond the scope of this article, it is important to restate that a careful screening is the first step in identifying and changing the outcome of a woman and her fetus who are subjected to domestic violence. SUMMARY Domestic violence can occur in virtually any relationship. If a woman involved in an abusive relationship becomes pregnant, there is an increased risk for permanent harm to both the mother and fetus. Pregnancy can trigger an abusive partner to increase the type and frequency of violence, often targeting the abdomen with the intent to harm the fetus. Health care providers should be alert to physical and emotional signs of abuse, social signs of a pathologic relationship, and the associated maternal behaviors that can complicate recognition and care. REFERENCES 1. Parker B, McFarlane J, Soeken K. Abuse during pregnancy: effects on maternal complications and birth weight in adult and teenage women. Obstet Gynecol 1994;84(3):323-8. 2. Violence leads to high-risk pregnancies. In: Population VOLUME 6, NUMBER 2
reports: ending violence against women. Baltimore (MD): Population Information Program, Center for Communication, The Johns Hopkins School of Public Health; 1999. p. 1-3. 3. Gantara BR, Coyaji KJ, Rao VN. Too far, too little, too late: a community-based control study of maternal mortality in rural west Maharastra, India. Bull World Health Organ 1998;76(6): 591-8. 4. Bullock L, McFarlane J. Higher prevalence of low birth weight infants born to battered women. Am J Nurs 1989;89:1153-5. 5. Gorrie TM, McKinney ES, Murray SS. Intrapartum complications In: Foundations of maternal newborn nursing. Philadelphia: WB Saunders; 1994. p. 652. 6. Bohn DK, Parker B. Domestic violence and pregnancy: health effects and implications for nursing practice. In: Campbell JC, Humphreys J, editors. Nursing care of survivors of family violence. St Louis (MO): Mosby; 1993. p. 156-72. 7. Corry BA. Domestic violence and your unborn baby. In: Domestic violence and pregnancy [pamphlet]. Alhambra (CA): Peace Offerings; 1999. p. 1-2.
8. Gerber-Smith L. The pregnant trauma patient. In: Cardona VD, Hurn PD, Mason PJB, Scanlon AM, Veisse-Berry SW, editors. Trauma nursing: from resuscitation through rehabilitation. 2nd ed. Philadelphia: WB Saunders; 1994. p. 667-92. 9. Emergency Nurses Association. Trauma and pregnancy. In: Trauma nursing core course [Provider Manual]. 4th ed. Park Ridge (IL): Author; 1995. p. 285-302. 10. Geberth VJ. Modes of death. In: Practical homicide investigation. 3rd ed. Boca Raton (FL): CRC Press; 1996. p. 306-8. 11. Newberger EH, et al. Abuse of the pregnant woman and adverse birth outcome. JAMA 1992;267(17):2370-2. 12. Screening for domestic violence in the emergency department/urgent care, OB/GYN, and family planning setting. In: Preventing domestic violence: Clinical guidelines on routine screening. San Francisco (CA): The Family Violence Prevention Fund; 1999. p. 9-12.
Access to International Journal of Trauma Nursing Online is now reserved for print subscribers! Full-text access to International Journal of Trauma Nursing Online is now available for all print subscribers. To activate your individual online subscription, please visit International Journal of Trauma Nursing Online, point your browser to http://www.mosby.com/trauma, follow the prompts to activate your online access, and follow the instructions. To activate your account, you will need your subscriber account number, which you can find on your mailing label (note: the number of digits in your subscriber account number varies from 6 to 10). See the example below in which the subscriber account number has been circled: Sample mailing label
This is your subscription account number
**************************3-DIGIT 001 SJ P1 FEB00 J065 C: 1 1234567-89 U 05/00 Q: 1 J. H. DOE 531 MAIN ST CENTER CITY, NY 10001-001
Personal subscriptions to International Journal of Trauma Nursing Online are for individual use only and may not be transferred. Use of International Journal of Trauma Nursing Online is subject to agreement to the terms and conditions as indicated online.
APRIL-JUNE 2000
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Saunders 47
Screening for Domestic Violence During Pregnancy Elizabeth E. Saunders, RN, CEN, EMT-P Domestic violence is an international social issue and significant cause of trauma. Pregnant women are at risk for intentional trauma and pose unique challenges for care. Patients are often not truthful about the mechanism of injury and are reluctant to seek care. Prenatal and postpartum care can be adversely affected if the woman continues in the abusive relationship. A careful approach to screening all pregnant trauma patients is presented to help clinicians with assessment for intentional trauma. (Int J Trauma Nurs 2000;6:44-7.)
omestic violence is a tragic cause of worldwide trauma. It has no boundaries; it has been reported in all cultures, races, ages, sexes, educational levels, and socioeconomic groups, and is especially tragic when the victim is a pregnant woman. A US study of 1103 African American, Hispanic, and white urban female patients concluded that 1 in 5 teens and 1 in 6 adult women in the study had experienced abuse during their pregnancy.1 Internationally, a study of more than 400 villages and 7 hospitals in 3 districts of Maharastra, India, revealed that 16% of all deaths during pregnancy were a result of domestic violence and that domestic violence was the second largest cause of deaths in pregnancy.2,3 Around the world, as many as 1 in every 4 women is physically or sexually abused during pregnancy, usually by her partner.2 For the purpose of this discussion, it will be assumed that the abuser is a man, although a woman may also be the perpetrator. Pregnancy often marks the initiation or escalation of violence for women. Pregnancy may be viewed as a time of vulnerability, and for some
D
Elizabeth E. Saunders, RN, CEN, EMT-P, is a Clinical Nurse III, Emergency Department, at Sound Shore Medical Center of Westchester, New Rochelle, New York. Please write [email protected] with comments. Reprint requests: Elizabeth E. Saunders, RN, CEN, EMT-P, 125 North Dr, Staten Island, NY 10305. Copyright © 2000 by the Emergency Nurses Association. 1075-4210/2000/$12.00 + 0 65/1/106858 doi:10.1067/mtn.2000.106858 44 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Saunders
women it marks the loss of financial or emotional autonomy. The physical, emotional, and financial changes associated with pregnancy can be seen as an opportunity for an abusive partner to establish power and control over the woman. Whatever the cause, abuse during pregnancy is responsible for
Pregnancy often marks the initiation or escalation of violence for women. injuries, adverse birth outcomes, and death. Trauma care providers need to be aware of the signs and symptoms indicative of possible abuse and screen patients to find, educate, and discuss resources, as well as offer referrals. The pregnant patient must then be allowed the autonomy to opt for the services that she feels are safe for her and her fetus. SCREENING FOR DOMESTIC VIOLENCE IN THE TRAUMA CARE SETTING Table 1 provides a list of recommendations for how to conduct a routine screening of patients for domestic violence.
Medical and social history Trauma care begins with the assessment and stabilization of physical injuries. When possible, a detailed medical, obstetrical, and social history should be obtained in private. A confidential screening for domestic violence will help VOLUME 6, NUMBER 2
providers to identify social and physical problems that can affect the outcome of the resuscitation phase of trauma care and pregnancy. Women who are enmeshed in a cycle of domestic violence may have sporadic, delayed, or no prenatal care, be homeless, or have a history of substance abuse and poor nutrition. The patient should be asked about current and past abuse, previous obstetrical complications, outcomes of previous pregnancies, and the birth weights of infants. Pregnant women who are victims of violence are 4 times more likely to give birth to low birth weight neonates4 (<2500 g or 5.5 lb)5 than those who are not victims of violence. The nurse should be attentive for social cues of a patient’s potentially abusive home life. Victims of abuse do not always have the ability to leave their living situation, access to transportation, or use of telephones. They may not have the means to obtain immediate medical treatment and may only seek out medical care after they or the fetus is in distress. Isolation is a common tactic used by the abuser to maintain control, and the abused women may delay acute treatment to avoid discovery of the abuse. If the patient is suspected to be a victim of domestic violence, the nurse can ask “what if” questions to help determine how the woman’s partner “typically” reacts to various situations. Research suggests that an abuser tends to feel jealous, angry, or insecure.6 The partner may feel abandoned and jealous of the woman receiving
The enlarged gravid abdomen is a frequent target during an assault because the batterer intends to harm the fetus.
attention from family, friends, and health professionals. He may feel threatened by the loss of control when the woman seeks prenatal care or treatment for injuries.7 An insecure partner may place an emphasis on the mate’s physical appearance and dislike the outward appearance caused by pregnancy.7 There may be resentment toward the woman for the added responsibility of her pregnancy and the birth of a child.7 Table 2 lists methods used by an abuser to maintain emotional control over a victim of domestic violence. APRIL-JUNE 2000
Table 1. Recommendations for conducting routine screening for domestic violence • All pregnant women regardless of age should be routinely screened at each prenatal visit and emergency department visit. • Pregnant women in lesbian relationships should be screened for domestic violence. • Screening should be done in woman’s primary language with an interpreter who is not a friend or family member. • Pregnant women should be screened for prior incidents of domestic violence. • Trauma care providers should be aware of cultural issues and factors that influence a woman’s perception of abuse. • Screenings should be done face-to-face when the patient is alone and in a confidential, private setting. • Patients should be asked straightforward questions and asked to provide a medical and social history. • The trauma care provider should be nonjudgmental to maintain communication with the patient. From “Screening for Domestic Violence in the Emergency Department/Urgent Care, OB/GYN, and Family Planning Setting.”12
Mechanism of injury Intentional injuries are often the result of the victim being pushed, shoved, choked, kicked, punched, beaten, shot, stabbed, bitten, or burned. The woman often attempts to hide the true mechanism of injury in an attempt to protect the abuser and avoid greater reprisal. Trauma care providers should compare the pattern of injury with the reported mechanism. For example, a pregnant woman tends to fall backward, landing on her back and buttocks.8 Isolated soft tissue injuries to the neck, face, or anterior abdomen that are attributed to a fall should raise suspicion. The enlarged gravid abdomen is a frequent target during an assault because the batterer intends to harm the fetus.7 Abdominal injuries that are a result of blunt or penetrating trauma can cause life-threatening complications for the mother and fetus. The most common type of penetrating injury seen during pregnancy is a gunshot wound.8 Stab wounds are not as common and tend to have a better prognosis for the mother and fetus.9
Physical assessment Soft tissue injuries that are in multiple stages of healing on the neck, breasts, abdomen, and geniINTERNATIONAL JOURNAL OF TRAUMA NURSING/Saunders 45
Table 2. Methods used by an abuser to maintain emotional control of a victim of domestic violence Method Isolation
Economic control
Examples 1. Preventing or prohibiting prenatal care visits or access to health care 2. Denying access to family or friends 3. Denying access to transportation 4. Denying access to telephone or mail communication 1. Withholding money 2. Taking woman’s earnings 3. Not permitting woman to work outside of home 4. Making statements such as “How will you support the baby without me?”
Destruction of property
1. Destroying toys, gifts, clothing set aside for birth; newly decorated nursery 2. Destroying mother’s personal, precious items
Emotional withholding
1. Not expressing feelings related to the pregnancy 2. Ignoring the needs of the pregnant woman 3. Denying paternity
talia are highly suspicious for intentional abuse. Wounds to the hands, outer aspects of arms, or anterior surface of legs are characteristic of a woman trying to defend herself. Certain injuries are indicative of the victim being dragged (eg, loss of hair or bald patches) or restrained (eg, abrasions or bruises of the extremities, fingernail marks to the throat). If the patient was manually strangled, petechial hemorrhages may be seen in the conjunctiva, or the victim may have bitten her tongue.10 The patient may have bites or cigarette burns to the breasts. Blunt and penetrating force can result in maternal hemorrhage; rupture of the uterus, liver, spleen, or amniotic membranes; premature labor; shock; or death of the mother or fetus. The fetus may have generalized hemorrhage, fractures, intracranial hemorrhage, or intrauterine growth retardation. Depending on the stage of gestation, spontaneous abortion, placental hypoperfusion, hypoxia, 46
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Saunders
preterm delivery, low birth weight, or stillbirth may occur. Abuse to the genitalia can produce abrasions, lacerations, or hematomas of the labia or vagina.
Emotional assessment It is not uncommon for victims to experience severe stress from an abuser who uses methods to maintain emotional control (Table 1). Stress decreases the woman’s ability to obtain adequate nutrition, rest, exercise, and medical care and can be a factor in depression and suicide attempts. Abused women may use ineffective coping mechanisms, such as drug, alcohol, and nicotine abuse. Physiologically, prolonged stress causes the release of maternal catecholamines that can result in placental hypoperfusion and preterm delivery.11 FOLLOW-UP CARE FOR VICTIMS OF DOMESTIC VIOLENCE Good trauma care for a victim of domestic violence does not stop with treating the physical wounds. An abused pregnant woman and her fetus will remain in danger as long as they stay in a relationship that has potential for additional harm. If there is evidence of intentional trauma, the patient’s long-term care will be determined by individual physical and social needs, hospital protocols, and state law. Although a full discussion of that care is beyond the scope of this article, it is important to restate that a careful screening is the first step in identifying and changing the outcome of a woman and her fetus who are subjected to domestic violence. SUMMARY Domestic violence can occur in virtually any relationship. If a woman involved in an abusive relationship becomes pregnant, there is an increased risk for permanent harm to both the mother and fetus. Pregnancy can trigger an abusive partner to increase the type and frequency of violence, often targeting the abdomen with the intent to harm the fetus. Health care providers should be alert to physical and emotional signs of abuse, social signs of a pathologic relationship, and the associated maternal behaviors that can complicate recognition and care. REFERENCES 1. Parker B, McFarlane J, Soeken K. Abuse during pregnancy: effects on maternal complications and birth weight in adult and teenage women. Obstet Gynecol 1994;84(3):323-8. 2. Violence leads to high-risk pregnancies. In: Population VOLUME 6, NUMBER 2
reports: ending violence against women. Baltimore (MD): Population Information Program, Center for Communication, The Johns Hopkins School of Public Health; 1999. p. 1-3. 3. Gantara BR, Coyaji KJ, Rao VN. Too far, too little, too late: a community-based control study of maternal mortality in rural west Maharastra, India. Bull World Health Organ 1998;76(6): 591-8. 4. Bullock L, McFarlane J. Higher prevalence of low birth weight infants born to battered women. Am J Nurs 1989;89:1153-5. 5. Gorrie TM, McKinney ES, Murray SS. Intrapartum complications In: Foundations of maternal newborn nursing. Philadelphia: WB Saunders; 1994. p. 652. 6. Bohn DK, Parker B. Domestic violence and pregnancy: health effects and implications for nursing practice. In: Campbell JC, Humphreys J, editors. Nursing care of survivors of family violence. St Louis (MO): Mosby; 1993. p. 156-72. 7. Corry BA. Domestic violence and your unborn baby. In: Domestic violence and pregnancy [pamphlet]. Alhambra (CA): Peace Offerings; 1999. p. 1-2.
8. Gerber-Smith L. The pregnant trauma patient. In: Cardona VD, Hurn PD, Mason PJB, Scanlon AM, Veisse-Berry SW, editors. Trauma nursing: from resuscitation through rehabilitation. 2nd ed. Philadelphia: WB Saunders; 1994. p. 667-92. 9. Emergency Nurses Association. Trauma and pregnancy. In: Trauma nursing core course [Provider Manual]. 4th ed. Park Ridge (IL): Author; 1995. p. 285-302. 10. Geberth VJ. Modes of death. In: Practical homicide investigation. 3rd ed. Boca Raton (FL): CRC Press; 1996. p. 306-8. 11. Newberger EH, et al. Abuse of the pregnant woman and adverse birth outcome. JAMA 1992;267(17):2370-2. 12. Screening for domestic violence in the emergency department/urgent care, OB/GYN, and family planning setting. In: Preventing domestic violence: Clinical guidelines on routine screening. San Francisco (CA): The Family Violence Prevention Fund; 1999. p. 9-12.
Access to International Journal of Trauma Nursing Online is now reserved for print subscribers! Full-text access to International Journal of Trauma Nursing Online is now available for all print subscribers. To activate your individual online subscription, please visit International Journal of Trauma Nursing Online, point your browser to http://www.mosby.com/trauma, follow the prompts to activate your online access, and follow the instructions. To activate your account, you will need your subscriber account number, which you can find on your mailing label (note: the number of digits in your subscriber account number varies from 6 to 10). See the example below in which the subscriber account number has been circled: Sample mailing label
This is your subscription account number
**************************3-DIGIT 001 SJ P1 FEB00 J065 C: 1 1234567-89 U 05/00 Q: 1 J. H. DOE 531 MAIN ST CENTER CITY, NY 10001-001
Personal subscriptions to International Journal of Trauma Nursing Online are for individual use only and may not be transferred. Use of International Journal of Trauma Nursing Online is subject to agreement to the terms and conditions as indicated online.
APRIL-JUNE 2000
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Saunders 47