A Client at 8 Months Gestation Tells the Nurse That She Knows Her Baby Listens to Her

Number 733

The Committee on Obstetric Practice

This Committee Opinion was developed by the American College of Obstetricians and Gynecologists' Committee on Obstetric Practice in collaboration with committee members Rebecca Jackson, MD and Meredith L. Birsner, MD, and with the assist of Sharon Terman, JD, and Liz Morris, JD.

ABSTRACT: In the United States, it is mutual for women, including mothers and pregnant women, to piece of work outside the home. Working during pregnancy is generally prophylactic. For those in high-risk occupations or with medically complicated pregnancies, piece of work accommodations oft tin can permit for connected safe employment. The major employment issues concerning pregnant women include pregnancy-related discrimination, piece of work accommodations that allow connected employment, job-protected get out, and wage replacement while on leave. Workplace discrimination related to being pregnant and pregnancy-related harassment, including discrimination in the hiring process, is prohibited by federal and state law. There is no federal police guaranteeing comprehensive accommodations for meaning and postpartum workers. Current federal and land laws provide protection for some meaning women, simply not others, because of eligibility requirements and land-by-country differences. Past writing appropriate notes to employers, obstetrician–gynecologists and other obstetric care providers can exist instrumental in obtaining accommodations for their patients who are able to continue working. Accommodations that allow a woman to keep working are the most reliable style to guarantee pay, benefits, and job protection. Obstetrician–gynecologists and other obstetric care providers too tin assist pregnant women and their partners by providing them with information and resources that might assist them meliorate empathise their employment rights. All the same, in cases for which potential job discrimination has occurred, accommodations are denied, extended medical leave is necessary, or when other complex employment questions arise, legal assistance should exist obtained.

Recommendations

The American Higher of Obstetricians and Gynecologists makes the following recommendations:

Working during pregnancy is mostly safe. For those in loftier-risk occupations or with medically complicated pregnancies, piece of work accommodations often can permit for continued safe employment.
By writing appropriate notes to employers, obstetrician–gynecologists and other obstetric care providers tin be instrumental in obtaining accommodations for their patients who are able to go on working. Accommodations that allow a woman to keep working are the most reliable style to guarantee pay, benefits, and job protection.
Medical go out is finite and is often unpaid or partially paid. Women typically are expected to render to work or risk losing their jobs subsequently medical leave has been used. Obstetrician–gynecologists and other obstetric care providers can play a valuable function in informing women of potential furnishings on income or job security, particularly when extended leave is medically indicated.
Obstetrician–gynecologists and other obstetric intendance providers also tin assist significant women and their partners by providing them with information and resources that might help them better understand their employment rights. Nonetheless, in cases for which potential job discrimination has occurred, accommodations are denied, extended medical leave is necessary, or when other complex employment questions arise, legal assistance should be obtained.

Introduction

In the United States, information technology is common for women, including mothers and pregnant women, to work outside the dwelling. In 2015, 70% of all women with children younger than eighteen years participated in the labor force 1. Of meaning women, 56% piece of work full fourth dimension during pregnancy, and 82% of nulliparous women proceed to work to within the month before their due dates. Near women (73%) return to work within 6 months subsequently giving birth 2. The United States is the only adult state that does non have a national paid maternity or parental leave program, which leaves many pregnant women and their families without job protection, health insurance benefits, or wages at a vulnerable time. Therefore, obstetrician–gynecologists and other obstetric care providers tin help pregnant women continue to work when it is safe for them to do and so by requesting piece of work modifications or accommodations when indicated.

Employment laws and go out programs are complex and vary from state to state. If a pregnant woman cannot work for medical reasons, she, or her partner, or both, may be entitled to partially paid or unpaid job-protected get out. Past educating themselves regarding laws and leave policies, obstetrician–gynecologists and other obstetric care providers tin can aid their patients obtain the necessary accommodations and medical get out or help them place resources to address pregnancy-related chore discrimination.

Employment Issues for Meaning Women and Parents

The major employment problems concerning pregnant women include pregnancy-related discrimination, work accommodations that permit connected employment, task-protected leave, and wage replacement while on leave. After delivery, the issues center on lactation accommodations and leave for physical recovery, bonding, and caring for the child. (For federal and state laws related to these problems see Table 1 or the For More Data section.)

Employment Considerations During Pregnancy and the Postpartum Period

Pregnancy Bigotry

Workplace discrimination related to being significant and pregnancy-related harassment, including discrimination in the hiring process, is prohibited by federal and land law. Nonetheless, cases of pregnancy bigotry reported to the U.S. Equal Employment Opportunity Commission are increasing 3. Exemplar cases include women who were fired later on divulging that they were pregnant, meaning women who were held to college standards than other workers (such every bit being tested to ensure they are capable of doing their jobs), women who were forced to take leave because they were pregnant, or who were pressured to stay home for the health of their fetus.

The Pregnancy Discrimination Deed requires that pregnant employees exist treated the aforementioned as nonpregnant employees who are similar in their power or disability to piece of work and makes it illegal to hogtie a woman to accept medical get out considering of pregnancy if she is capable of continuing her chore. Information technology is also illegal to finish a woman'south employment for being meaning; yet, nearly one third of allegations to the U.S. Equal Employment Opportunity Commission claim termination occurred solely because of the employee's pregnancy 3. If a patient reports possible pregnancy-related chore bigotry, it is recommended that she consult with an employment law attorney or complimentary legal aid service (see the For More Information section).

Accommodations for Pregnancy and Lactation

Accommodations are work modifications that let a person to go along to safely perform the essential functions (primary duties) of the task, thereby allowing continued pay and benefits. Examples related to pregnancy include taking additional residue breaks; having a stool or chair bachelor for sitting; avoiding potentially dangerous activities, such as climbing a ladder; or working flexible hours to attend prenatal appointments. A national survey of meaning working women showed that although 53% felt the need to change their job duties, 37% never requested such changes. Furthermore, of those who did request accommodation, at to the lowest degree ix% were denied 4.

In that location is no federal law guaranteeing comprehensive accommodations for pregnant and postpartum workers. Electric current federal and state laws provide protection for some meaning women, but not others, because of eligibility requirements and state-by-state differences. Nether the Americans with Disabilities Deed, the definition of inability was recently expanded to include less-severe, temporary impairments, such as those that are pregnancy-related. This expansion entitles significant women to piece of work accommodations as long as those accommodations do not create an undue burden for the employer. In addition, federal police and some country laws require employers to provide reasonable suspension time and a private space (not a bathroom) to pump chest milk. The Pregnancy Bigotry Act entitles pregnant and lactating workers to the same accommodations offered to other workers with similar limitations arising out of a temporary disability. Even so, fifty-fifty with these protections in place, legal rights to accommodations for pregnancy and lactation remain patchwork and incomplete. Past writing appropriate notes to employers, obstetrician–gynecologists and other obstetric care providers tin can be instrumental in obtaining accommodations for their patients who are able to continue working Box one. Accommodations that allow a woman to keep working are the near reliable way to guarantee pay, benefits, and chore protection.

How to Write a Work Accommodation Annotation

Only suggest a work restriction or modification when medically necessary. Outset equally modest equally possible and calibration up to requite the employer more flexibility for accommodations.
Endeavour to determine whether the requested job modification limits an essential role (eg, a typist must be able to blazon). Talk over possible accommodations to request and the risks of requesting (eg, if an adaptation to an essential part is requested that cannot be provided, the employer may identify employee on medical go out. If she is not eligible for medical leave, she may be terminated).
Specifically state the work restriction (eg, "Due to her pregnancy-related status, it is medically advisable that Ms. Xyz not represent prolonged periods [more 2 hours continuously] without a intermission or without an opportunity to sit").
It is not necessary to suggest an accommodation but this can be helpful to the employer and employee. Be equally specific as possible (eg, "I recommend the following reasonable accommodation: Providing a stool or a fifteen-minute break every 2 hours"). Avoid general statements, such as "no concrete activity" or "decreased stress." Do not request "light duty," as this has a specific legal definition, and non all employers have a low-cal duty pick. Asking for light duty may lead to a denial of the accommodation, leaving medical go out as the only selection.
State that your patient is able to continue to work (eg, "Ms. Xyz is able to continue working with a reasonable accommodation").
Country the expected duration of the modification (which tin can be extended).

Jackson RA, Gardner S, Torres LN, Huchko MJ, Zlatnik MG, Williams JC. My obstetrician got me fired: how work notes can harm pregnant patients and what to exercise near information technology. Obstet Gynecol 2015;126:250–iv.

Job-Protected Get out for Pregnancy and Bonding

Job protection and continuation of health benefits (without pay) while on leave are afforded nether the federal Family and Medical Leave Deed (FMLA) every bit well as a number of state laws. Nevertheless, because of eligibility criteria, just approximately lx% of workers in the United States are eligible for FMLA protection Table 1 or the For More Data department) v. In particular, workers with less than 1 year of employment are ineligible, and to exist covered by the FMLA a worksite must be part of a business firm with at least 50 employees. Withal, individual visitor policies may provide leave for pregnancy, fifty-fifty for newly hired employees. In exercise, even workers eligible for FMLA protection may not be able to beget unpaid get out or must cutting their leave short because of financial or workplace force per unit area 5.

The FMLA guarantees that an employee must exist able to return to her previous or a similar chore with the same pay, benefits, and working conditions. Information technology affords 12 weeks of total leave, which may be used for prenatal appointments, pregnancy-related medical weather condition (including those related to miscarriage or pregnancy loss), physical recovery, and infant bonding. One time FMLA leave time has been used, the employee is expected to return to piece of work. The FMLA does not guarantee connected pay while on go out. Therefore, in states that practise non have boosted protections, working as long as possible during pregnancy allows for more than time off postpartum and for continued income, which is important for many women. The FMLA likewise allows time off for parents to intendance for an adopted or foster child.

A few states currently offer variations on the FMLA for pregnancy disability leave, or family leave, or both. Physicians and patients should be aware of state laws regarding pregnancy leave protections and eligibility requirements, provisions for pregnancy accommodation, and workplace breastfeeding rights. Upwards-to-date lists of pertinent laws in each country are available at world wide web.abetterbalance.org/know-your-rights and www.dol.gov/wb/maps/.

If there are complications during pregnancy or the postpartum period that crave more than 12 weeks of go out, leave can exist further extended under the Americans with Disabilities Act as a "reasonable accommodation" provided information technology does not create an undue hardship for the employer 6. Importantly, medical leave is finite and is often unpaid or partially paid. Women typically are expected to return to work or gamble losing their jobs afterwards medical get out has been used. Therefore, obstetrician–gynecologists and other obstetric care providers tin play a valuable role in informing women of potential effects on income or job security, specially when extended leave is medically indicated. If feasible and medically appropriate, an accommodation that allows a woman to keep working is a meliorate choice for job protection. If a adult female is expected to need extended leave because of a medical status, consultation first with her employer and, if necessary, with an attorney or gratis legal assist service is suggested (see the For More Information section).

Income Replacement During Leave

In a 2014 United Nations Survey of 185 countries, only Papua New Republic of guinea and the Usa did not accept national paid maternity exit policies seven. Although government agencies and many large companies offering paid leave to their employees, many women, especially those who piece of work for smaller companies or in low-wage jobs, are not provided with paid maternity exit. For example, a Bureau of Labor survey showed that just 42% of private-sector workers reported access to paid personal medical leave and simply xiv% had access to paid family go out 8. Furthermore, Hispanic workers, lower-wage earners, and workers with less than a college education have less access to paid go out nine. Paid leave has been shown to increase the proportion of women, especially low-income women, who return to piece of work after giving birth and is associated with college rates of female employment 10.

Paid parental leave (additional go out for bonding beyond recovery from childbirth) has been linked in observational and geographic ecologic studies with better wellness for women and their infants, including lower rates of mental health symptoms 11, college rates of breastfeeding and babyhood immunizations 12 and, in some European studies, lower infant mortality 13. The American College of Obstetricians and Gynecologists' policy on paid parental leave is available at world wide web.acog.org/-/media/Statements-of-Policy/Public/92ParentalLeaveJuly16.pdf?dmc=1&ts=20170419T1540420564.

Some states offer partial income replacement for pregnancy disability through payroll deduction-funded inability programs. Benefits vary by state and change frequently. Online sources for up-to-date state benefits tin can be plant at www.abetterbalance.org/know-your-rights 6 and www.nationalpartnership.org/research-library/work-family unit/paid-leave/land-paid-family-leave-laws.pdf seven (encounter also the For More than Information section). Chiefly, these programs provide wage replacement just practice not guarantee job protection during the disability period; chore protection is guaranteed through the FMLA, or state laws, or both, and must be requested from the employer separately. Income replacement for get out taken to bond with a new kid is currently available just in a few jurisdictions.

If a adult female is terminated because of issues related to pregnancy, childbirth, or lactation, she may exist eligible for unemployment benefits, depending on state laws. Consultation with an employment lawyer or complimentary legal assistance service is recommended (see the For More Information section).

Safety of Work During Pregnancy

Multiple studies confirm that it is generally safety for a adult female with an uncomplicated pregnancy to piece of work throughout most of the pregnancy without adverse effects for the woman or her infant 14 15 16. However, accommodations may need to be fabricated for women who work in occupations in which they are exposed to teratogenic toxins (eg, pesticides and heavy metals), in very physically demanding professions, and in jobs that have an increased hazard of falls or injuries (specially as the pregnancy progresses and the woman's center of gravity shifts). Women with complicated pregnancies also may need work modifications to go along to piece of work safely. For instance, a woman with gestational diabetes may demand additional break time besides every bit a private space for glucose testing and snacking. Evidence on the safety of specific working conditions is summarized in the following sections.

Toxic Occupational Exposures in the Workplace

Although more than 100,000 compounds are used in diverse occupational settings, very few accept been sufficiently studied to draw conclusions about potential reproductive harms 17. Exposures that more often than not are believed to pose a adventure of fetal anomaly, miscarriage, or other adverse pregnancy outcomes include the following: heavy metals (eg, lead, mercury, and arsenic), all classes of pesticides and sure herbicides, specific solvents (eg, toluene and benzene), ionizing radiation, and certain chemotherapeutic agents (eg, methotrexate) 17 18 nineteen xx 21. The U.S. Occupational Prophylactic and Wellness Administration regulates exposure to chemicals and radiation in workplaces. Patients who piece of work with chemicals should do and so with acceptable ventilation and protective gear, such as gloves and masks. Fifty-fifty if information technology is unknown whether a specific chemical poses risks to pregnancy or lactation, if a patient is bothered past it, an adaptation can be requested. For patients who want more information about risks of a specific chemical, they may obtain the chemical's safety data sheet (formerly cloth condom information sheets), which includes basic information about the risks of exposure during pregnancy. Further information on workplace exposures is available at CDC-NIOSH: world wide web.cdc.gov/niosh/topics/repro/specificexposures.html.

Miscarriage

Results of studies that examined the clan of workplace activities with miscarriage are mixed. A meta-analysis of predominantly retrospective cohort and case–control studies showed an increased risk of miscarriage or stillbirth with night work compared with mean solar day shifts (relative risk, 1.51; 95% CI, ane.27–1.78) 22. The single prospective study showed no event just but included miscarriages later 12 weeks of gestation 23. Working more than 40 hours per week was associated with a small increased take chances overall (relative hazard, i.36; 95% CI, 1.25–1.49), only the association was not pregnant when limited to higher quality studies. No increased take chances was establish for mixed shift piece of work, lifting more than than 100 kg/day (220 lb), or continuing more than 6 hours per day. However, a contempo large retrospective accomplice report of occupational lifting from Denmark showed elevated take a chance of miscarriage associated with all-encompassing lifting 24. The chance ratio was ane.38 (95% CI, 1.ten–ane.74) for a full weight load per day of 101–200 kg (approximately 220–440 lb) and 2.02 (95% CI, i.23–3.33) for a daily load greater than 1,000 kg (approximately 2,200 lb) equally compared with nonlifters.

A second meta-analysis focused on shift work 25. All studies included in the analysis were retrospective and had aligning for confounders. Night shifts were associated with early on spontaneous pregnancy loss (adapted odds ratio, 1.41; 95% CI, 1.22–1.63), defined by spontaneous loss of pregnancy before 25 weeks of gestation.

It is difficult to draw definitive conclusions from these studies because of their methodological bug, including substantial variation in the definitions of exposures, incomplete command of misreckoning, and potential for recall bias. At most, there appears to be a slight to modest increased gamble of miscarriage with night shift work and extensive occupational lifting, although these levels of increased risk could also be attributed to bias and misreckoning.

Preterm Birth

Iii recent meta-analyses that examined preterm birth ended that there is a slight to small-scale increased risk of preterm birth associated with some work conditions fifteen 16 26. For example, a systematic review and meta-analysis establish a statistically significant association between preterm delivery and continuing and walking at work for more than 3 hours a day (odds ratio [OR], 1.3; 95% CI, one.1–i.6), lifting and carrying more v kg (11 lb) (OR, 1.three; 1.05–ane.six), or physical exertion at work (OR, 1.4; 95% CI, ane.2–i.7) 16. A 2013 systematic review and meta-analysis establish a statistically significant association between preterm delivery and working more than xl hours a week (OR, 1.2; 95% CI, i.1–i.three), standing more than 4 hours a day (OR, 1.2; 95% CI, 1.1–one.3), and shift work (usually defined as either shift or night work, OR, ane.i; 1.0–1.3) 15. On the other manus, some other study constitute no association between shift piece of work and preterm commitment only did find a slight increased gamble among those who worked more than 40 hours a week (OR, ane.three; one.0–1.5) 26. In all three studies, the odds ratios were lower when the meta-analyses were restricted to higher quality studies.

Although small merely pregnant associations were found for sure workplace activities, it is questionable whether these results were due to bias and confounding or to an actual consequence. All studies included in the analysis were observational, and nigh were retrospective. Furthermore, studies had differing definitions of work atmospheric condition, failed to command for important confounders, and often assessed occupational exposure after delivery, which could lead to retrieve bias. In addition, in nigh studies, the timing of the work exposure was either not noted or was limited to the first trimester, which made information technology difficult to depict conclusions virtually working in the second and tertiary trimesters. In decision, there may exist a slight increased take chances of preterm delivery for sure types of occupational characteristics; however, given the observational nature of these studies, this increased risk may be due entirely to bias and confounding.

Physically Demanding Work

Physically enervating work such every bit heavy lifting, excessive repetition, awkward postures, and prolonged periods of sitting or standing is associated with low back hurting and musculoskeletal disorders in the general population 27. Accommodations that take been shown to mitigate the effects of prolonged continuing in the nonpregnant population include floor mats, sit-stand up workstations, pinch stockings, and supportive shoes 28. Low back hurting and musculoskeletal disorders may be exacerbated by physical changes associated with pregnancy. Although the effectiveness of these accommodations has not been specifically studied in pregnancy, it is reasonable to consider such accommodations in symptomatic meaning women. In addition, falls are the leading cause of occupational injury amid the general population nineteen. Pregnant women are at an increased gamble of falls because of joint laxity and a shifting center of gravity. Thus, consideration of accommodations for some pregnant women whose piece of work may be associated with an increased run a risk of falls may be warranted with advancing gestational age.

Lifting, in particular, poses a risk of musculoskeletal injury and low back pain. The National Found of Occupational Safety and Health recommends limits for lifting in the workplace and has recently made recommendations specifically for meaning workers 29. Recommended weight limits are given for nine lifting zones (based on the pinnacle of the elevator and distance from the body), three lifting patterns (infrequent, repetitive short elapsing, repetitive long elapsing), and 2 gestational phases (less than 20 weeks versus twenty weeks or more than) Figure one. For an ideal lift (defined every bit a 2-handed lift with no twisting and starting at 71–132 cm [28–52 in] higher up the ground), the recommended weight limit is sixteen kg (36 lb) for women in the early on gestation menses who accept an exceptional lifting pattern and 12 kg (26 lb) for women in the later gestation menstruation who take an infrequent lifting pattern. For women in the early gestation menses and those in the later gestation period who have a repetitive, curt-duration lifting pattern (less than ane hour at a fourth dimension followed by a minimum of one hour nonlifting activity), the recommended weight limit is 14 kg (30 lb)and 10 kg (22 lb), respectively. For women in the early on gestation menstruum and those in the afterwards gestation menstruum who take a repetitive, long-duration pattern, the recommended weight limit is 8 kg (eighteen lb) and 6 kg (xiii lb), respectively.

Employment Considerations During Pregnancy and the Postpartum Period

Accommodation Requests

Working during pregnancy is generally safety. For those in high-risk occupations or with medically complicated pregnancies, work accommodations oft can let for continued safe employment. Obtaining work accommodations allows a woman to continue to work and, thus, ensures connected pay, benefits, and chore protection. When a patient requests a note for a workplace accommodation, the commencement step is to determine medical necessity. Many women are concerned that piece of work may be harmful to their pregnancies and reassurance is frequently sufficient. If work accommodations are medically indicated because of pregnancy complications or specific symptoms, physicians should explore the patient's duties at piece of work to decide whether accommodation might be possible and offer knowledge and additional resource regarding the potential implications of taking medical leave (eg, information technology is fourth dimension limited and often partially paid or unpaid and may affect the availability or length of postpartum leave). Physicians should work with their patients to determine their essential job duties. The physician and patient should determine together whether it is possible to propose reasonable accommodations that would allow the patient to continue to perform her essential job functions. Employers also may exist able to suggest accommodations. For case, an administrative assistant may have a few duties that involve lifting, but lifting is not an essential component of her work and could reasonably exist accommodated by the employer. Withal, if the patient has a job that involves heavy lifting as an essential role and she is unable to elevator, the employer may exist unable to provide an accommodation (unless another less strenuous job is available). In such a case, the patient may need to take medical leave or risk existence terminated if she is not eligible for leave.

The fashion in which medical certification notes are written can affect whether an employee is able to be accommodated and, thus, continue working Box 1[email protected], a land-specific, online note-writing resource, was developed by the University of California's Hastings Heart for Work Life Police force to assist medical providers in writing legally appropriate piece of work accommodations messages: www.pregnantatwork.org (see the For More than Information section).

Obstetrician–gynecologists and other obstetric intendance providers also can help significant women and their partners by providing them with information and resources that might aid them better understand their employment rights. Nevertheless, in cases for which potential job bigotry has occurred, accommodations are denied, extended medical get out is necessary, or when other complex employment questions arise, legal aid should be obtained. Local resources, in the course of social work referral, also tin can be provided. There are several toll-free legal hot-lines bachelor, some of which besides provide gratuitous or low-toll legal services (run into the For More than Information department).

For More Information

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this certificate that may be helpful for ob-gyns, other health care providers, and patients. Yous may view these resources at www.acog.org/More than-Info/Employment Considerations.

These resources are for information but and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists' endorsement of the arrangement, the system's website, or the content of the resources. The resources may alter without discover.

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Source: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/04/employment-considerations-during-pregnancy-and-the-postpartum-period