Keywords
pregnant surgeon - breastfeeding surgeon - maternity leave - parental leave
The proportion of women in medicine has increased dramatically. While in 1965 only
6.9% of U.S. medical school graduates were women, most recent data from 2017 demonstrate
that half of the matriculants are females (50.7%).[1] General surgery is still male predominant; 36.6% of applicants were women in 2017,
and ultimately women comprise 23% of full-time faculty positions.[2] The rigorous nature of the job and negative attitudes toward pregnancy may deter
some students from a surgical career.[3] Despite this, we feel that the passion and commitment to a career in surgery and
the desire to start and raise a family are certainly not mutually exclusive.
While in the past a pregnant surgeon rarely existed, you will most certainly encounter
one in contemporary practice. Whether you are the pregnant surgeon, it is your colleague
or mentee, or you are in a position of leadership, you will be affected. Pregnant
surgeons are no longer an insignificant part of the surgical workforce, and this is
the new reality. What has been called a “surgical residency baby boom” occurred after
2000, as 35% of female residents and 41% of male residents had a child during residency,
compared with 7 and 24%, respectively.[4] Therefore, it is imperative that we adopt a team approach to the pregnant surgeon.
Considering pregnancy a “problem,” inconvenience, imposition, or burden to others
is counterproductive.
This study addresses the physical, logistical, and financial challenges facing the
pregnant surgeon while also providing some practical advice for both pregnant surgeons
and those considering pregnancy, as well as their valued colleagues, mentors, and
administrators. There is a paucity of data on many of the issues surrounding the pregnant
surgeon, and thus we also provide our own perspectives.
Physical Challenges
There are physical challenges for the pregnant surgeon that vary by trimester. Notably,
every pregnancy is different and it is remarkably hard to “plan” and anticipate how
you will feel. As such, there is a balance of planning and flexibility to accommodate
the unexpected. While the decision to share pregnancy news with one's workplace is
highly personal, it is advantageous to be forthcoming with the news not only if symptomatic
or in need of workplace accommodations but also to allow for advance planning of the
call schedule and maternity leave as much as possible.
First Trimester
The increase in estrogen and the β-subunit of human chorionic gonadotropin by the
placenta, starting as early as 10 days after fertilization, can cause nausea and vomiting
after only 1 month. During the first trimester, nausea and vomiting is reported by
75%, with 35% requiring therapy. Fatigue during early pregnancy due to elevated levels
of progesterone can be debilitating. The advice given at prenatal visits to rest often,
eat well, and have small meals every 1 to 2 hours, and exercise can be a near impossibility
for a surgeon either in training or practice.
Some practical advice is to keep crackers and snacks in your pockets. The post anesthesia
care unit (PACU) usually has a supply in case of emergency. Many find some relief
from motion sickness bands (which you cannot wear in the operating room [OR] of course),
but medication may be necessary for some. The American College of Obstetricians and
Gynecologists recommends the use of pyridoxine (vitamin B6) alone or in combination
with doxylamine as the first-line therapy for nausea and vomiting in pregnancy.[5] Doxylamine can cause drowsiness and is used alone as a sleep aid; therefore, we
suggest not taking this prior to working. Evidence is limited on the safety of serotonin
5-HT3 inhibitors such as ondansetron, although its use for pregnancy-related nausea
and vomiting appears to be increasing.[5] If OR smells are bothersome, a drop of peppermint oil on the outside of your mask
can make an otherwise nauseating situation tolerable. In anticipation of fatigue during
the first trimester, if overnight calls can be minimized, it may be advantageous to
do so. Do not overextend workplace or other obligations during this time to allow
for sufficient weekend rest after tough weeks in the OR.
Second Trimester
As pregnancy progresses, many experience relief of nausea and improvement of fatigue;
however, many do not. By the second trimester, cardiac output and glomerular filtration
rate increase approximately 30 to 50%. As such, urination occurs more frequently and
may interrupt a long case. The increase in gastroesophageal reflux can be attributed
to elevated progesterone, which relaxes the smooth muscle of the lower esophageal
sphincter and diaphragmatic hiatus. Many will need antacids. It is in the second trimester
that the gestational diabetes screen is performed, identifying those at risk for hyper-
and hypoglycemia. Round ligament pain can cause sharp lower abdominal pain, which
may become more common during the second trimester as the enlarged uterus moves around
with changes in position. Additionally, leg cramps can occur, which may be related
to low iron or potassium.
As the second trimester is usually a good time to operate on a pregnant patient, it
is also a relatively “good” time to be a pregnant surgeon. In general, many feel better
during the second trimester, and this can be an opportunity to take more calls or
book more involved cases. For longer cases, stay well hydrated and plan bathroom breaks
at more opportune times such as after the specimen is out, following rigid proctoscopy
(before scrubbing back in), or before closing. To minimize reflux, eating small and
frequent low-fat meals, and avoiding citrus food, chocolates, and spice can help.
For those with gestational diabetes, eating small and frequent meals is also beneficial.
Stretching and heating pads can aid in minimizing round ligament pain, as would bananas,
meat, or supplements for leg cramps.
Third Trimester
The third trimester brings its own challenges. Edema is related to an increase in
corticotropin-releasing hormone, which ultimately increases aldosterone and cortisol.
During the third trimester, compression of the inferior vena cava by the enlarged
uterus will exacerbate edema. Back pain is problematic even for the surgeon who is
not pregnant. In the third trimester, altered center of gravity, combined with weight
gain, can exacerbate or lead to back pain, which is reported in more than two-thirds
of pregnant women and typically increases with advancing pregnancy. A Cochrane review
of randomized controlled trials found evidence that exercise and osteomanipulative
therapy or a multimodal approach (manual therapy, exercise, and education) reduced
lower back pain.[6] Additionally, difficulty sleeping can plague the pregnant surgeon during the third
trimester.
Braxton Hicks contractions (false labor contractions) are most commonly noticed in
the third trimester and are uterine contractions that do not result in measurable
cervical change until they intensify near the onset of true labor. These contractions
are unpredictable with irregular intensity, can last as long as 2 minutes, and are
typically uncomfortable rather than painful.[7] Staying hydrated and intermittently changing position can help prevent and limit
the frequency of these distracting but harmless contractions during long days in the
OR. The advice for alleviation of Braxton Hicks contractions is largely impractical
for incorporation into the day of the pregnant surgeon (lie down if you have been
standing, take a warm bath, etc.), but having a few extra glasses of water can help
as it is thought they may be brought on by dehydration.[8]
Carpal tunnel syndrome can present during pregnancy and can be particularly troublesome
for a surgeon. A prospective study of 639 Dutch pregnant women found that carpal tunnel
syndrome was reported by 34%, with more severe symptoms after 32 weeks' gestation
and independently associated with higher levels of fluid retention and sleeping problems.[9] Avoiding exacerbating activities, holding surgical instruments in a more ergonomic
fashion, taking frequent breaks and performing stretching exercises, and using a heating
pad or splint can be helpful to reduce symptoms. Minimizing endoscopy and laparoscopy
at the earliest onset of symptoms may limit exacerbation.
There are many strategies for minimizing the physical challenges of the third trimester.
Wearing compression stockings is helpful and may prevent development of unsightly
and painful varicosities, but ensure that they are lightweight so that you do not
overheat. Staying comfortable in hospital-issued scrubs is a challenge in the third
trimester. In a pinch, you can use a hemostat to clamp the pants to the top, preventing
the embarrassing drop of the pants while scrubbed (do not forget to include the hemostat
in the count). Alternatively, wearing a belly band over scrub pants with an untucked
top works as well.
At a minimum, regular stretching and a maternity back support belt may be helpful
for musculoskeletal pain. Positioning self-retaining retractor systems to accommodate
a pregnant belly should not be a problem, as surgeons with a large waist circumference
have been operating successfully for decades. To manage overheating, cool the room
if the patient is euthermic, use ice packs, use a cool washcloth, or break for a drink
of cold water. Your OR nurses will be your biggest allies in keeping you comfortable
and are true lifesavers in times of need.
A summary of physical challenges by trimester and associated practical recommendations
can be found in [Table 1].
Table 1
Challenges and recommendations by trimester
|
Challenges by trimester
|
Practical recommendations
|
|
First
|
|
Nausea and vomiting
|
Keep snacks in your pockets
Eat frequent and small meals
Wear motion sickness bands
Place peppermint oil on you mask to avoid nauseating odors
Talk to your OB about medication options if symptoms are refractory
|
|
Fatigue
|
Minimize overnight calls if possible
Minimize workplace and other obligations
Rest on the weekends
|
|
Second
|
|
Reflux
|
Eat small low-fat meals, and avoid citrus food, chocolates, spices, and caffeine
Take antacids or talk to your obstetrician about medications options
|
|
Frequent urination
|
Stay well-hydrated despite the inconvenience of doing so
Plan opportune times to take bathroom breaks during long cases
|
|
If you are feeling better
|
Schedule longer cases
Make up any missed call
|
|
Third
|
|
Edema
|
Wear compression stockings
Wear loose-fitting shoes
|
|
Overheating
|
Stay well-hydrated
Ensure socks are lightweight
Decrease the room temperature, use ice packs or a cool washcloth
Take a break and drink a glass of cold water
|
|
Carpal tunnel
|
Minimize laparoscopy and endoscopy
Take breaks and stretch wrists frequently
Wear a wrist splint
- Use a heating pad
|
|
Back pain
|
Stretch frequently
Use a heating pad
Wear a maternity back support belt
|
When to Stop Major Cases
There are no published guidelines on this subject. Anecdotes abound of pregnant surgeons
going into labor while operating or having Foley catheters during long cases. Remaining
physically active in the form of 150 minutes of moderate intensity exercise per week
is recommended throughout an uncomplicated pregnancy[10]; however, “exercise” does not necessarily translate into the physical rigors of
operating. Lifting restrictions are vague, but guidelines still in use by obstetricians
include repetitive lifting < 11 kg as a recommended maximum at 40 weeks' gestational
age.[10] Is this equivalent to holding a St. Mark's retractor in an obese pelvis? We may
never know and thus recommend a common-sense approach.
During training, one can continue involvement in major cases for as long as one feels
physically up to the challenge, given there is a coresident or fellow who could step
in and assist the attending surgeon if necessary. Given the strict case numbers and
stringent requirements for completion of residency and fellowship, it is to the advantage
of the trainee to remain clinically active in the OR even until the estimated date
of confinement as long as so permitted by the obstetrician.
As faculty, the decision of when to stop performing major cases is more difficult,
as there are no published guidelines. Full term, defined as 37 weeks' gestational
age, seems a logical time to transition to minor cases. At term, it would be wise
to have a colleague available should assistance become necessary. The same may apply
to seeing patients in the office and taking calls; however, it is less altering to
a patient's life should their clinic appointment need to be cancelled on a relatively
short notice than their surgery. Lastly, while it can be frustrating to the busy pregnant
surgeon to taper her practice in anticipation of maternity leave, for some situations,
the timing works out fortuitously. For example, a patient with rectal cancer could
undergo neoadjuvant chemoradiation during the later portion of the surgeon's pregnancy
and be ready for surgery once the pregnant surgeon returns from maternity leave.
Risks for the Pregnant Surgeon
Risks for the Pregnant Surgeon
Pregnancy Risks: Infertility, Advanced Maternal Age, Preterm Labor
Delaying pregnancy due to career aspirations is commonplace in surgery. A survey of
365 female urologists found that they were 7 to 8 years older than the average American
woman at the time of their first child.[11] Findings were similar in thoracic surgery, as a survey of 113 female thoracic surgeons
revealed that 98% delayed pregnancy.[12] In 2014, a study by Phillips et al demonstrated that female surgeons had their first
child at a mean age of 33.1 years, which increased to 35.4 years if reproductive assistance
was necessary.[13] On average, surgeons in the United States start their first staff appointment at
the age of 36 years.[14] Advanced maternal age is considered age 35 years or older and is associated with
infertility, cesarean delivery, low-birth-weight infants, and neonatal intensive care
unit (NICU) admission.[15] Therefore, a planned delay in childbearing until completion of surgical training
incurs the aforementioned risks.
Are risks for pregnant women in procedural specialties different from women in other
areas of medicine? A study by Scully et al. sought to answer this question. Although
women in procedural fields were slightly older than their nonprocedural counterparts,
time to conception, rates of reproductive assistance use, missed work due to pregnancy-related
issues, preterm labor, and cesarean section were not statistically different between
groups.[16] Results from the postgraduate trainee cohort revealed similar findings. Specifically,
trainees in procedural specialties were slightly older than their nonprocedural colleagues
and were more likely to require reproductive assistance, but there were no differences
in missed work due to pregnancy-related issues, preterm labor, and cesarean section
rate. Notably, this study did not include those who were ultimately unsuccessful in
becoming pregnant and thus may underestimate the extent of the issue.[17]
Occupational Hazards
In general, occupational risks to pregnant surgeons are the same as for the nonpregnant
surgeon population (and are discussed in detail in the chapter on Workplace Exposures
on page XXX), although the magnitude of the exposure risk and treatment may differ.
In general, taking the usual appropriate safety measures and invoking universal precautions
are the best strategies.
There are, however, a few specific occupational risks for the pregnant surgeon that
are worthy of further discussion. Minimizing exposure to anesthetic gasses and avoidance
of iodine-based scrub are advised as the former crosses the placenta and can affect
the fetus, and the latter can affect development of the thyroid or cause maternal
subclinical hypothyroidism.
Standard precautions when handling sharps and use of double gloves should minimize
exposure to the hepatitis C virus (HCV) and HIV. In the unfortunate event that the
pregnant surgeon is exposed, the risk of seroconversion is approximately 0.3% for
HIV and approximately 2% for HCV. A qualitative test for HCV RNA should be performed
6 to 8 weeks from exposure and treatment should be initiated immediately if positive.[18] Maternal to fetal transmission of HCV is rare and occurs almost exclusively in viremic
women, and, similarly, transmission of HIV to the fetus can be reduced to <1% with
the appropriate management.[19]
In contrast to some other surgical and procedural specialties, exposure to ionizing
radiation is generally rare in colon and rectal surgery aside from placement of sacral
neuromodulators and endoluminal colonic stents. In such cases, the dose of radiation
is well under the threshold for what is considered safe, although it is important
to monitor cumulative exposure during pregnancy and to always wear well-fitting lead.
Most state guidelines consider exposures under 50 mrem per month to be a safe dose,
corresponding to 100 to 1,000 fluoroscopic examination of 5 minutes each.[20]
Maternity Leave
A staggering number of surgical training programs and institutions do not have an
official maternity leave policy. Lack of an established, transparent policy can result
in stress on behalf of both the pregnant trainee and program director. It may also
dissuade trainees from having the potentially dreaded “conversation” till they are
further along in pregnancy, leaving less time to make appropriate coverage arrangements.
A study of 54 plastic surgery programs found that only 36.5% had a formal maternity
leave policy, and of those that did, only half included plans for coverage should
pregnancy complications arise.[21] Fewer than half of the programs with maternity leave policies specified call requirements
and coresidents' roles for coverage. Of the program directors without a specified
maternity leave policy, 25% thought that doing so would lead to insufficient weeks
of training and clinical experience.
Given the lack of formal maternity leave policies in surgical residency programs,
it is not surprising that the duration of maternity leave in trainees has been shown
to be short, as suggested by the literature. A survey of 738 postgraduate medical
trainees found that procedural trainees were significantly more likely than their
nonprocedural colleagues to have a short maternity leave (defined as <6 weeks after
vaginal delivery and <8 weeks after cesarean section).[17] Furthermore, procedural trainees were more likely to rely on themselves or their
peers to arrange coverage for missed work, and this translated to lower overall career
satisfaction. Similar results were found in a survey of 243 female urologists, as
a short maternity leave was twice as common in trainees and correlated with decreased
career satisfaction.[22]
With this in mind, the American Board of Surgery (ABS) allows for 6 weeks off per
year in either of the last 2 years of residency without prior approval. Similarly,
residents may take an additional 2 weeks off during the first 3 years of residency
(to complete 142 weeks instead of 144) to accommodate medical conditions including
pregnancy.[23] And although it requires prior approval from the ABS, the chief year can be extended
through the end of August, or five clinical years of residency can be completed in
6 years.
In accordance with the maternity leave specified by the Family and Medical Leave Act
in 1993,[24] the Association of Women Surgeons proposed that women surgeons be allowed 4 weeks
of paid maternity leave in addition to a 2-week vacation, additional timeoff not be
a reason for termination, and residents would not have to make up for missed calls.[25] These were by no means binding requirements, and it was left up to the discretion
of program directors and institutions to formalize a maternity leave policy.
The financial impact of maternity leave is significant. A study by Scully et al reported
that female proceduralists contributed a larger percentage of their total household
income than their nonproceduralist colleagues.[26] This study found that 77 to 82% of female physicians reported losing income due
to maternity leave, and 53% of women in procedural fields reported losing greater
than US$10,000. The vast majority of female proceduralists had a contract that did
not include maternity leave, and more than half (54%) of those who did attempt to
negotiate for leave were unsuccessful. Upon return to work, 23% of proceduralists
had to complete missed call shifts, 4.9% owed money to their practice, and 20% lost
a productivity bonus as many had compensation plans based on relative value unit (RVU)
targets.[26] These findings beg for a better solution. Ideally, one would negotiate maternity
leave into her contract, with stipulations for duration of leave, protection from
excess calls, financial compensation, and adjustment of RVU targets. Furthermore,
while it is beyond the scope of this study, we would also like to stress the importance
of incorporating a fair and transparent parental leave policy, as the transition to
parenthood does not solely impact the mother.
Lastly, it is important to set realistic expectations for work productivity during
maternity leave. Far from vacation, maternity leave is exceedingly exhausting emotionally
and physically. It is also a critical bonding period between the mother and the baby.
Do not plan to use this time to “catch up” on missed work, attend research meetings,
or complete projects.
Postpartum Challenges
Returning to practice following maternity leave is challenging—in many ways much more
so than pregnancy. Mornings become unpredictable as there is now a baby to feed and
clothe, and items to prepare for whoever will be caring for the child. Many mornings
come in the wake of sleepless nights. As such, arriving to work on time can be stressful
and will usually involve a team effort. Some may elect to start their workday later
if this is logistically possible within the confines of the busy practice setting.
Additionally, there are an abundance of well-baby pediatrician visits, which most
mothers would like to attend if possible. Other significant challenges include prolonged
NICU stays, neonatal illness, and younger siblings at home. Caring for a baby is a
team effort, and, often, roles of both parents evolve in a shared parenting and earning
framework.[27]
Plan for more help with childcare and household tasks than you think you may need,
as no one has ever complained about having “too much help.” Help with childcare is
obvious, but also making arrangements for house cleaning, errands, laundry, and other
time-consuming housework can be critical. Chronic sleep deprivation makes the postpartum
period challenging as well. Consider a graduated increase in work responsibilities
or returning on a part-time basis. This is challenging, as the covering partners have
been eagerly awaiting your return. For administrators and department chairs, recognition
of these significant postpartum challenges and having flexibility during this time
of transition are essential to the long-term success of the surgeon mother.
Childcare
Finding childcare can be quite stressful. For those of us who do not have family or
a stay-at-home partner immediately able to provide childcare, finding a nanny, au
pair, or day care is time-consuming. Even the most resilient stay-at-home partners
need a break, especially considering the long hours they will be with the child while
the surgeon is at work. Start the childcare search well in advance of the anticipated
delivery, particularly if in search of a day care. Many facilities have long waitlists,
as people place their unborn child on the waiting list the moment they find out they
are pregnant. Often hospitals have affiliated day cares, with somewhat more flexible
and extended hours, although most surgeons' hours will require help with pickups and/or
drop-offs. Your hospital may also have an e-mail or web-based nanny Listserv, which
may provide recommended nannies from other physicians whose needs may have changed.
Advantages to a nanny or au pair are flexibility and care for the baby even during
sickness. Some even find two nannies, as the full-time hours of a single employee
may not suffice, particularly in a dual-career family. Despite the challenges, finding
a fantastic childcare solution is possible. Speaking from our personal experiences,
a wonderful caregiver can become loved as part of the family.
Breastfeeding
Accommodating breastfeeding during return to practice is often the most difficult
postpartum challenge. The American Academy of Pediatrics recommends exclusive breastfeeding
for approximately 6 months, with continuation for 1 year or longer if mutually desired
by the mother and the infant.[28] Similarly, the World Health Organization (WHO) recommends exclusive breastfeeding
for at least 6 months.[29] Additionally, in some settings, there are cultural expectations and stigma associated
with formula feeding of newborns. As a result, mothers can experience a significant
amount of pressure from the society and their physicians regarding breastfeeding.
However, initiating and sustaining lactation remains a challenge for many women.[28] A survey-based study of mothers who are physician demonstrated that of those who
initiate breastfeeding, 41.7% sustain to 1 year, which is better than the national
rate of 27%. However, less than one-third reported the ability to sustain breastfeeding
to their personal goal. The most frequently cited challenges included inadequate time,
schedule inflexibility, and insufficient space.[30]
At the point of returning to work, the formerly pregnant surgeon is getting even less
sleep than previously, managing the emotions and concerns involved with leaving a
new baby at home, and has caloric requirements higher than during pregnancy (500 vs.
300 extra kCal/day). Feeding a newborn generally occurs every 3 hours during the day,
and therefore pumping breast milk should occur at roughly the same frequency to avoid
diminishing supply. Accordingly, an appropriate place to do so with access to an electrical
wall outlet and a refrigerator is necessary. Unfortunately, designated lactation rooms
are often located far from the ORs in a hospital, if there are actually any at all.
Among plastic surgery training programs, only 20% of those surveyed who had formal
maternity leave policies also had defined allowances for breastfeeding upon return
to work.[21] It requires dedication, openness, and flexibility of the entire care team to facilitate
regular pumping breaks during the OR for a surgical trainee, but it is possible if
desired.
Staff surgeon mothers who continue to breastfeed upon returning to work have their
own set of challenges. While they may be able to arrange their schedule to accommodate
pumping, a day in the life of a surgeon is far from predictable. The greatest challenge
is with long OR cases, whether expected or unplanned. Some practical advice to maximize
your time operating is to pump immediately before a case, right up until the time
of incision. Have an assistant facilitate the setup. Keep a pump in a locker or nearby
area to minimize setup and bring icepacks if a refrigerator is not readily available.
A capable trainee may be able to proceed independently in a limited fashion. Even
a quick break can help prevent leaking until a more opportune time is available. Ultimately,
while there are no perfect solutions for the lactating surgeon, choosing to entirely
forgo long cases during breastfeeding may be an even greater challenge to the early
career surgeon, often at the cost productivity and potentially lost referrals.
Ultimately, it is a personal choice if or how long to breastfeed based on what is
best for the mother and child. Formula feeding is not a failure. A study of exclusively
formula-fed infants using age-based formulas from ≤ 14 days through 4 months demonstrated
noninferiority for growth metrics when compared with WHO standards.[31] There are multiple strategies for low milk supply, including pumping more frequently,
increasing rest, fluid intake, and adding various foods such as oatmeal, almonds,
or fenugreek seeds. By contrast, if desired, to facilitate a gradual wean from breastfeeding,
certain herbs (parsley, peppermint, sage, oregano), topical application of cabbage
leaves, antihistamines, and gradually eliminating pumping can accelerate the process
while minimizing discomfort associated with engorgement.
Conclusion
As more women join the surgical workforce, pregnant surgeons are becoming increasingly
common. There are significant challenges faced by the pregnant and postpartum surgeon,
as well as her colleagues and administrators, but with awareness, planning, and a
supportive environment, there are sustainable solutions. By raising awareness of the
specific physical, logistical, and financial challenges facing the pregnant surgeon,
we hope to prepare pregnant surgeons, their colleagues, mentors, and administrators.
The commitment to a healthy and sustainable pregnancy and maternity leave for surgeons
is a worthy investment to sustain a full and productive career thereafter.
