Advice for Pregnant Anaesthetic Trainees

So, you’re pregnant – CONGRATULATIONS! Hopefully this is very exciting news for you, but it’s likely to be a bit daunting. Here’s some tips about dealing with work during your pregnancy that I wish someone had told me when I was pregnant for the first time.

  

Safety at work

Anaesthetic gases:

Historically there was a link between exposure to anaesthetic gases and an increase in the risk of spontaneous miscarriage and congenital abnormalities. However, this risk is thought to have diminished with the use of newer anaesthetic agents and scavenging.1,2, 3 It may be prudent to avoid lists with high turnover inhalational inductions, such as paediatric dental lists, especially during the first trimester.

 

Radiation:

There is a risk of teratogenicity and cancer development with exposure to radiation, especially early in the first trimester (the most dangerous time is up to 8/40 gestation). Provided that the usual precautions are strictly adhered to (appropriate shielding and radiation safety practices), the radiation dose is unlikely to exceed a dangerous level and foetal risk should therefore be negligible. Routine monitoring show that 98% of staff working within imaging departments (including nuclear medicine) will not exceed potentially harmful doses. 4

 

MRI:

There is no evidence of harm to the foetus with exposure to MRI, however staff are advised to avoid being in the scan room whilst scanning is taking place.

 

Infectious diseases:

Certain infections are known to be harmful in pregnancy so contact should be avoided; these include CMV, chicken pox, rubella, toxoplasmosis etc.

 

Manual handling:

During pregnancy, hormonal changes increase the likelihood of ligament or muscular injury. Extra care should be taken when moving patients, and manual handling should be avoided where possible, especially after 24/40.

 

Shift work:

There is no definite evidence which links shift work and adverse pregnancy outcomes.5

 

When to tell people

This is really up to you – legally you should let your employer know before 25 weeks but it’s probably not sensible (or practical) to leave it that long! Lots of people start telling everyone after they have had their first scan at around 12 weeks. However, the first trimester can be one of the toughest time to be at work (nausea, tiredness, concerns over safety etc.) so it may be worth having a quiet word with your educational supervisor or college tutor or anyone friendly and trustworthy so you can come up with a sensible plan and change lists etc. if necessary.  Pregnancy related employment laws can only be used to protect you once your employer knows that you are pregnant.

  

Who do you need to tell?

The list of people that need to know about your upcoming maternity leave is quite extensive!

  • Educational supervisor
  • College tutor
  • Rota writer
  • Anaesthetic secretaries
  • Training program director
  • Deanery programme manager
  • Hospital HR department/payroll – you will need to provide them with your MATB1 form before 25/40 (this will be given to you by your midwife or doctor after 20/40)
  • BMA – they can arrange reduced subscription rates
  • RCOA – they can stop your membership payments for the duration of your maternity leave (you will not get the BJA/BJA education etc. but should still be able to access your eportfolio). The college also need to know the exact date when you are returning to work and how much annual leave has been taken, so they can alter your CCT date.
  • AAGBI –  they can put your membership on hold
  • MDU/MPS – maternity leave is regarded as a career break so you do not have to pay during this time.
  • GMC – although you need to continue to pay your GMC fees to remain on the list of registered medical practitioners, you may be able to pay the reduced rate (this depends on your income during the tax year), so it will be worth enquiring about.

  

Antenatal appointments

You are legally entitled to a ‘reasonable’ amount of paid time off work to attend antenatal appointments (although this obviously will only work if your employer knows that you pregnant!). Clearly it is important to be sensible about this and to bear in mind training opportunities and current modules etc. During an uncomplicated singleton pregnancy, you can expect to have ultrasound appointments at approx. 12 and 20 weeks, and midwife appointments at approx. 8, 16, 24, 28, 32, 36, 38 weeks (less for 2nd and subsequent pregnancies)

 

Risk assessment

You will need to meet up with a nominated senior (in some trusts this is your educational supervisor, in others it is the departmental line manager) to complete a risk assessment form. If any risks are identified, then the employer must remove them or provide alternative arrangements.

 

Stopping on-calls etc.

The decision to stop on-calls and nights is up to you and will depend on how you are feeling and how your pregnancy is. Lots of people stop them at around 24-28 weeks, some much earlier, and some people carry on until they go off on maternity leave. If you do decide to stop on calls then in order to protect your pay, the hours need to be made up during daytime hours so you may end up working almost every day and miss out on the days off that you get after a weekend or set of nights. There is also a possibility that your CCT may need to be extended, although this is rare in practice. If you do want to carry on with your on-calls you may be able to ask the rota writers very nicely to schedule you for the potentially ‘lighter’ on-calls – i.e. cardiac ICU or obstetrics rather than ICU at Derriford. You could also consider swapping any on-calls late in your pregnancy for ones earlier on. You may also be able cut down your hours (and your pay!) – just beware of doing this too early as your maternity pay is calculated on the amount that you are paid between approx. 17 and 25 weeks (see further down for details). You can discuss all your options with you medical HR department.

 

One option to make work a little easier in the last few months is to spread out your annual leave – for example taking every Wednesday off during the last 6 weeks to break up the week. It’s worth sitting down and planning all of this as early as possible.

  

Preparing professionally for maternity leave

It is important to dedicate some time during the second half of your maternity leave getting your admin sorted to allow a smooth return to work (however far off this may seem!) Start thinking about this as early as possible, as you may well find that you don’t feel like doing much extra work in those last few weeks of work. Ensure that your logbook and WBAs are up to date and all completed modules have been signed off. Finish off any ongoing audits, presentation etc. or hand them over thoroughly. You may think that you will have time to finish this kind of thing when you have a newborn but the reality may be a little different! It may also be useful to write some ‘how to’ notes or ’recipes’ for standard anaesthetic cases – most people find that they practical procedures such as cannulation, epidurals, central lines etc. come back very quickly but specifics such as what analgesics you would give for certain cases is easily forgotten.

 

When to start maternity leave

Maternity leave can be taken any time from 29/40. Most anaesthetic trainees will continue until between 34 and 38 weeks. You need to consider tiredness, commuting, feeling bloated, baby brain, etc. etc. There are also the practicalities of working with a massive bump – intubating gets harder and harder, as does running to arrests or fitting in a lift when transferring a patient to CT (from personal experience!). Any leftover annual leave can be tacked onto the beginning or end of maternity leave as it is not usually possible to roll it over. This is worth bearing in mind as if you take a month of accrued AL at the end of ML before returning to work, it will be paid at the pay scale of pre-mat leave (bonus if you are returning LTFT having been FT before, as you will get a month of full time rate pay for a month of LTFT leave – i.e. potentially using only 12 days of accrued leave = 4 weeks off if you are LTFT 60%, but this will be paid at FT rate)

 

How long to take off

Again, this is entirely individual – some people can’t wait to get back to using their brains, having adult conversations and having time for a hot cup of tea, whilst others want as much time at home as possible. You obviously also need to consider your financial situation and the individual. By adding on accrued annual leave it is possible to take 13 months off. Legally you need to give your employer an expected return date – if you want to bring this forward then you need to provide 28 days notice. It’s best to keep your department up to date with any changes to your plans as early as possible to allow for rota writing etc. 

 

Maternity Pay

Maternity pay is fairly complicated but here is a brief summary of what I think it’s all about.

 

Everyone is entitled to 52 weeks maternity leave (if they want it – the minimum you can take is 2 weeks?!)

NHS Occupational maternity pay:

-          You must have done 12 months of continuous service for NHS (not necessarily that particular trust) by the time you are 29/40.

  • 8 weeks - full pay
  • 18 weeks – half pay plus Statutory Maternity Pay (SMP)
  • 13 weeks –  SMP – currently £139.58 a week
  • Remaining 13 weeks – unpaid

 

This is what most trainees will get – however if you have recently moved trusts then you may not be eligible for SMP. In this case, you should still be able to claim maternity allowance (MA) which you need to get from the job centre (you can fill in a form online or visit your local job centre) instead of getting SMP from your trust. The amount that you will actually receive will be exactly the same. This is a common scenario for trainees as we move trusts regularly so it’s important to be aware of this. The MA paperwork needs to be completed by you as early as possible (but not before 26/40). It can also become complicated when two trusts argue over who should be paying the different maternity pays so you may need to get expert advice and pay attention to your payslip to make sure you don’t miss out.

 

It is also possible to get caught out if you have taken some time out of the NHS. In this case, you may be entitled to SMP alone (90% of full pay for 6 weeks, then flat rate SMP for 33 weeks), or maternity allowance. This will depend when you came back to the NHS and which country you were working in.

 

The amount that you are paid is worked out by looking at your earnings during the ‘reference period’. This is the 2 months payslips (assuming that you are paid monthly) up to and including the last payday before the end of your ‘qualifying week’ which is the 15th week before the week that your baby is due. It’s worth noting that anything that causes your pay to be reduced during these months will be reflected in your maternity pay (i.e. any money lost for junior doctors strike etc.). Similarly, any extra money earned (locums etc.) will increase your maternity pay. It is usually beneficial to stop paying childcare vouchers during this time (if it’s your second or subsequent pregnancy) as they will affect your maternity pay. An exception to this rule can be If you move trusts during your pregnancy – contact the childcare voucher manager who should be able to consider your individual case and advise you.

 

You can choose whether to get paid in this staggered way or whether it gets averaged out across your maternity leave (which may make budgeting etc. a little easier). Discuss this with your HR department.

 

In summary, maternity pay can be extremely complicated and often varies between individuals.  The best advice is to find someone in the HR department to guide you through it – each HR team should have someone who has some expertise in this area. The BMA also has a helpful maternity leave calculator which you can use if you are a BMA member.  

 

Benefits

During maternity leave you should continue to have all the usual contractual rights and benefits, except for remuneration. This includes study budget. Under the new 2016 contract, maternity leave is no longer considered in the criteria for advancement to a higher nodal pay point; the result is that it will take longer to progress between pay points.6

 

Childcare Vouchers

You and your partner can start claiming childcare vouchers from the day that your baby is born. This is a chunk of money that is taken off your pay before tax and NI contribution and can be used to pay for childcare. It is £243 per month if you earn less than £43000, or £124 a month if you are a high rate (40%) tax payer. This can save your family up to £150 a month so are definitely worth having. The vouchers can be used for nurseries, child-minder, nannies (if they are OFSTED registered), after school clubs, holiday clubs etc. They can be kept for 12-24 months (depending on which scheme your trust uses) before they are used; it therefore makes sense to start collecting them asap if you are planning on any of these types of childcare from the age of 12 months or before. Each trust seems to use a different scheme but they are all fairly similar and you can use online vouchers and payments so it’s easy once you get into it. Ask your HR department how to apply. 

 

Childcare options

Unless you’re lucky enough to have willing relatives nearby or a partner who wants to stay at home looking after the kids, then you’ll probably need to consider some kind of childcare for when you return to work. There are lots of options so take your time and speak to as many people as possible to work out which might suit you best. You need to consider your normal hours, how you will cope in the mornings getting yourself and a little one out of the house, what happens when your list overruns, how you will cope with nights and weekend shifts, what you can afford, whether somewhere closer to home or closer to work would suit you best etc.

 

Employing a nanny probably provides the most flexibility and avoids stressful mornings of dragging your child to nursery at the crack of dawn, but it is expensive (although this evens out a little when there are 2 or 3 kids) and you have to deal with all the employment issues yourself. Child minders can be great and often offer more flexibility than nurseries (i.e. earlier drop-offs and later pick-ups). Most nurseries have quite limited hours (by our standards!) but those closer to the hospital may be open from 7-6 for example. I’ve used a combination of all three so feel free to email me (at annafergusson@me.com) if you want any info.

 

The best place to start looking for childcare is to ask other friends and colleagues with kids – they may be able to recommend (or not recommend!) local places or people. Also ask around at local playgroups/baby groups. Your health visitor or children’s centre should also have a list and be able to make some recommendations. It’s also worth looking online – www.childcare.co.uk is a good starting point for finding nannies or child minders.

 

Finally, it’s worth thinking about your options as early as possible. Popular nurseries and child minders can be booked up months in advance (I’ve known friends who’ve put their name down on waiting lists straight after their booking scan!). If you aren’t sure yet what hours/days you’ll be working you could always book a full-time place and then change this once you’ve finalised your plans.

  

Coming back to work

How long you choose to take off will depend on your individual situation and baby. Coming back to work can be quite daunting but it all soon comes flooding back!

 

You can take some Keeping in Touch (KIT) days during your maternity leave. You can take 10 days (or 20 half ‘SPLIT’ days) which are paid at your hourly rate offset against the maternity pay/SMP that you would have normally received for that week. They can be used throughout maternity leave (except in the 2 weeks after birth) and can be used for standard lists or for attending trust induction, meetings, courses, conferences etc. They cannot be used in the annual leave that you have tagged onto the end of your maternity leave.

 

Prior to coming back to work you should have a meeting with your educational supervisor, or Return to Work Consultant Lead to make a plan regarding your Return to Work period (RTW).

The usual pattern is that you do several supervised lists (spread out over different specialities) – usually 2 sessions (one full day) for each month that you have been away. During this time, you will usually be required to complete a small number of work based place assessments. Once this settling back in period has been completed, you will meet up again with your supervisor to check you are feeling confident before starting again on the rota. These days can be taken as KIT days, or you can start work officially and have the rota writers not put you on call for the first few weeks (although this means you may have more regular on calls to catch up on those missed). A successful RTW period should not affect your CCT date. For more information on returning to work, please refer to the new and very useful RTW guide on the deanery website.

 

http://anaesthesia.peninsuladeanery.nhs.uk/about-us/returning-to-work-after-a-period-of-absence/

 

Returning to work Less than Full Time

Many trainees will choose to come back to work on a less than full time (LTFT) basis. The obvious advantages are that you get to spend more time with your family; the obvious major disadvantages are that you don’t get paid as much and your training takes much longer. The deanery isn’t legally required to automatically allow you to work LTFT but in reality it has rarely been an issue (especially in anaesthetics) so shouldn’t be a problem as long as you provide enough notice.  The minimum amount that you are allowed to do is 60% (unless there are exceptional circumstances). Other percentages (70, 80, 90%) are also possible although they may be harder to accommodate (especially when you are slot sharing rather than being alone in a full-time slot) and would need to be discussed on an individual basis with your TPD. Recently the LTFT options at Derriford have had to be restricted to no more than 60% due to problems getting all trainees through their essential modules (although this may change again in the future).

 

Working at 60% means no more than 28 hours a week – this essentially means that you work a 3-day standard week, approx. 1 in 8 weekends and days off in lieu of weekends worked etc. You usually nominate 3 days that you want to work (and arrange childcare for these days) – these days can be all together (i.e. mon, tues, wed) or spread out (i.e. mon, tues, fri). The advantage of doing mon, tues, wed or wed, thurs, fri is that you can do the standard 2 weekday nights without having to arrange alternative childcare for when you are post nights and meant to be looking after a toddler. You may need to have some flexibility and discuss days with your college tutor, anaesthetic secretary etc. before committing to exact childcare plans.

 

You will need to apply to the deanery to be allowed to switch to working LTFT – the deanery website and secretary should be able to provide you with more information and the relevant paperwork. It’s probably worth getting the process started asap. You also need to let you RCOA know so that your CCT date can be altered accordingly (very depressing!)

 

http://anaesthesia.peninsuladeanery.nhs.uk/about-us/policies-and-guidelines/peninsula-less-than-full-time/

 

Books/Courses on returning to work

There is a new book that has recently been published specifically designed for anaesthetic trainees and consultants that are returning to work after a gap – it provides lots of practical information as well as refreshing your memory of common clinical scenarios and important guidelines that you need to be aware of. Check It out on amazon - Returning to Work in Anaesthesia: Back on the Circuit by Plunkett, Johnson and Pierson. 

 

The RCOA provides guidance on its website in the career Breaks and Returning to Work section.

http://www.rcoa.ac.uk/document-store/career-breaks-and-returning-work

 

http://www.rcoa.ac.uk/careers-training/training-anaesthesia/special-areas-of-training/ltft-anaesthesia-z-guide

 

There are also a number of regional and national courses available including AAGBI run RTW refresher seminars and RTW simulation courses (such as the GASagain course).

 

References:

 

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

 

  1. Symington IS.  Controlling occupational exposure to anaesthetic gases. BMJ 1994; 309: 968-969.

 

  1. Lawson CC, Rocheleau CM, Whelan EA et al. Occupational exposures among nurses and risk of spontaneous abortion. Am J Obstet Gynaecol2012: 206 (4); 327

 

  1. Temperton DH.  Pregnancy and work in Diagnostic Imaging Departments 2nd Edition.  British Institute of Radiology 2009. http://www.rcr.ac.uk/docs/radiology/pdf/Pregnancy_Work_Diagnostic_Imaging_2nd.pdf

 

  1. Royal College of Physicians and Faculty of Occupational Medicine.  Physical and shift work in pregnancy:  occupational aspects of management.  2009. http://www.rcplondon.ac.uk/resources/physical-and-shift-work-pregnancy-guideline

 

  1. Junior doctors’ handbook on the 2016 contract. A guide to the new 2016 terms and conditions of service for doctors and dentists in training in England. September 2016. BMA