Risk Assessment

NHS Lothian is required to conduct a risk assessment of the work which new, expectant or breastfeeding mothers carry out, including the hazardous substances to which they are exposed. The risk assessment form should be completed jointly by the pregnant staff member with their line manager.

The required form is available on the Health and Safety intranet site

Any risk to the mother or baby which is identified must be eliminated or adequately controlled, or the nature of the work altered or their hours of work or conditions changed.

If conditions of the workplace cannot be "made safe" for the employee, then they should be sent home on full pay.

Working While pregnant

Every pregnancy is different and so too is your experience of working while pregnant. There are two things to consider- the impact that pregnancy related symptoms may have on your ability to work, and the impact that your work may have on your pregnancy. The former may include nausea and vomiting of pregnancy (up to hyperemesis) and you may find that fatigue exacerbates this. You may also find yourself to be significantly fatigued. Some may start to improve in the second trimester, while others may experience symptoms throughout pregnancy. Some may find that their mental health is impacted by pregnancy and others may have MSK pain arising from pregnancy. Others still will have complications of pregnancy or need extra input for chronic conditions. We include this because some doctors may feel obliged to “soldier on” - however - you will not be the first nor last doctor to need adjustments to your job if you do decide to seek them. We have included some examples of adjustments made by departments in the past below.

Many line managers will have completed previous risk assessments, however, many may not. We have included examples of risks which you may wish to consider below.

If the risks to which you are exposed cannot be adjusted, you should be considered for suitable alternative work. If this is not available, you may be suspended on paid leave. This is rarely necessary as there are frequently other non-patient-facing clinical roles or non-clinical roles (QI, Teaching) which a doctor may participate in.

Occupational Risks to Consider

These are some examples of risks which you may wish to consider and possible ways to mitigate them.

Night work/Shift Work/Long Hours

• You may wish to come off on calls during pregnancy, and some departments may arrange this routinely in the third trimester. If your department does not routinely offer this, you may wish to seek a fit note from your GP or midwife recommending amended duties, or to discuss with occupational health if you feel that you are unable to work on call shifts, or that they are exacerbating symptoms you have, or increasing the risk of your pregnancy.

• There are conflicting reports on whether long hours reduce foetal growth and increase the risk of preterm delivery. Recent meta-analysis (2019) suggesting shift work, and working >40 hours per week, increases risk of miscarriage and pre-term delivery.

[1] Meta-analysis (2011) - found that overall, any risk of preterm delivery, low birth weight, or small for gestational age arising from shift-work in pregnancy is small. [2] Cohort study published 2018 - working in a rapid cycling schedule of shift work may cause an increase in the incidence of preterm delivery in pregnant mothers. [3]

1. Cai C,Vandermeer B, Khurana R et al. The impact of occupational shift work and working hours during pregnancy on health outcomes: a systematic review and meta-analysis.

2. Bonzini M. Shift work and pregnancy outcomes: a systematic review with meta-analysis of currently available epidemiological studies. BJOG 2011; 118 (12): 1429-37

3. Davari MH, Naghshineh E, Mostaghaci M, et al. Shift Work Effects and Pregnancy Outcome: A Historical Cohort Study. J Family Reprod Health. 2018;12(2):84–88.

Manual Handling

• Hormonal changes increase susceptibility to injury and you may increasingly need to avoid this as your pregnancy progresses. This may be of more significance in some specialities (e.g. anaesthetics or surgical specialities where you may engage in regular manual handling) than others.

• In settings where you handle equipment, rather than patients, you may wish to seek occupational advice regarding alternative ways to do this.

Prolonged Standing

• Prolonged standing has been associated with pre-term delivery [4]. On a more practical level, it also exacerbates postural hypotension and you may need to be facilitated in remaining hydrated. You may also experience varicose veins in pregnancy, which may be exacerbated by prolonged standing.

4. Henriksen TB, Hedegaard M, Secher NJ, Wilcox AJ. Standing at work and preterm delivery. Br J Obstet Gynaecol. 1995 Mar;102(3):198-206.

Radiation

• Ionising radiation is toxic and teratogenic. The risk is greatest during the first 8 weeks. However, most staff working even within radiology will fall well below radiation dose limits. The RCR guideline below has much more detail on this topic.

• If you are in a speciality which involves radiation exposure, you should seek advice from the radiation lead and may be provided with a dosimeter if required, or provided with access to appropriate protective equipment.

• There is also some evidence regarding radiation in orthopaedic surgery available in this paper

• The RCR has advice on this topic available

MRI

• The RCR has a useful summary of potential risks from MRI in pregnancy here, which are felt to be low. However, it is advised that pregnant women do not remain in the scan room whilst scanning is underway.

Anaesthetic Gases

• Previously shown to increase risk of spontaneous abortion and congenital anomalies, but this risk has been significantly reduced since advent of scavenging. Anaesthetic trainees have been advised that it may be best to avoid lists with high exposure (e.g. rapid turnover facemask gas) in first trimester. [6]

6 Bovin JF. Risk of spontaneous abortion in women occupationally exposed to anaesthetic gases: a meta-analysis. Occup Environ Med 1997; 54 (8): 541-548.

Cytotoxic medications

• You may be advised to avoid direct exposure to chemotherapy during your pregnancy. Your departmental pharmacist may be able to give you further advice if this is of relevance to your case.

Infection Risk

• Exposure to infection will vary across specialities, but may occur in any unit. Some infections may be of more concern than others. For example, if you are aware that you are not immune to chickenpox or rubella, you may not wish to see such patients.

• It is also recognised that there is an increased risk of miscarriage, still birth and pre-term labour with viral illnesses such as influenza and COVID (7,8). You should be able to access vaccinations as per vaccine schedules via maternity services or workplace based programmes. You may, however, wish to avoid exposure to patients with such conditions. In some cases, it may be possible for another team member to see the patient, however, if you are working at a more senior grade (eg as paediatric/medical/obstetric/anaesthetic registrar), you may wish to work in a site where there are two registrars out of hours, or to come of on call rotas.

• FFP3 masks will require reassessment during pregnancy.

7. Lyu T, Liang C, Liu J, Hung P, Zhang J, Campbell B, Ghumman N, Olatosi B, Hikmet N, Zhang M, Yi H, Li X; of the National COVID Cohort Collaborative Consortium. Risk for stillbirth among pregnant individuals with SARS-CoV-2 infection varied by gestational age. Am J Obstet Gynecol. 2023 Feb

8. Gunnes N, Gjessing HK, Bakken IJ, Ghaderi S, Gran JM, Hungnes O, Magnus P, Samuelsen SO, Skrondal A, Stoltenberg C, Trogstad L, Wilcox AJ, Håberg SE. Seasonal and pandemic influenza during pregnancy and risk of fetal death: A Norwegian registry-based cohort study. Eur J Epidemiol. 2020 Apr;35(4):371-379. doi: 10.1007/s10654-020-00600-z. Epub 2020 Jan 16. PMID: 31950373; PMCID: PMC7192880.

Violence and Aggression

• Although violence may occur in any clinical setting, the risk of violence may be higher in ED or psychiatric settings. The risk that this poses may depend on the staffing levels in the department, security measures or lone working. Some departments may have established arrangements in place for approaching this risk, for example, avoiding out of hours or lone working in the third trimester.