Career Focus

Having babies as a surgical trainee

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7223.2 (Published 04 December 1999) Cite this as: BMJ 1999;319:S2-7223
  1. Scarlett McNally, specialist registrar in orthopaedic surgery
  1. Royal Sussex County Hospital, Brighton, BN2 5BE.

    Having a baby in the midst of surgical training posts might seem daunting. Scarlett McNally, a full time specialist registrar in orthopaedic surgery with two children (aged 21/2 years and 8 months), has some advice

    Some 60%of medical students are women. If surgical specialties remain a male preserve the standard of surgeons will fall. Several factors have made it easier for both men and women to combine a surgical career with having a family: CEPOD (the confidential enquiry in perioperative deaths) has reduced nocturnal operating, junior doctors” hours are reducing, the Royal Colleges of Surgeons” exams have become more structured, and ‘Calmanisation’ (with specialist registrar rotations) makes it easier to put down roots (for finding babysitters and créches).

    For a surgical consultant, having a baby should not be much different from the experience of any other professional woman. It is harder for a trainee. Pregnancy can be physically difficult, and having a child eats into all your spare time. These are difficult to correlate with early starts, unpredictable finishes, on call duty, studying for exams, writing papers, commuting to posts on a rotation, and a macho culture. However, training also occupies the time of peak fertility, before age 35.

    Maternity leave rights

    To qualify for maximum maternity leave, you must have been in continuous employment in the NHS for one year before the 11th week before your baby is due, so avoid gaps in service.1 A break of up to three months is allowed, and a fellowship post abroad for up to a year does not count as a break in service. Doing NHS locums is better than agency locums if you are likely to get pregnant soon after.

    You get eight weeks” leave on full pay, 10 weeks on half pay, and up to 34 weeks” unpaid leave with your job held open. You can start maternity leave any time between 11 weeks before your baby is due and the birth itself. During the paid part of maternity leave, you accrue annual leave and pension and keep your salary incremental date. No one seems to know whether you accrue study leave while on maternity leave. It would make sense to go on courses while pregnant. This is less physically demanding than working, and it is difficult to get away once the baby has arrived.

    After your leave, you have to return to work for at least three months (full or part time). If you are on rotation and your maternity leave straddles a changeover, you can return to the same post or go to the next post. It is your choice.

    You are required to give only three weeks” notice that you are leaving, and three weeks” notice confirming when you are coming back.A specialist registrar is allowed three months in total out of her rotation before the date of her certificate of completion of specialist training (CCST) changes, with each extra week being added on. The Blue Book allows senior house officers two weeks of maternity leave or sick leave out of each six month post.

    Pregnancy and breast feeding

    You must tell your employer that you are pregnant. The employer should perform a risk assessmentê If a risk is identified, you are entitled to be offered alternative work, to be exempted from the duties affected (such as being on call), or to be suspended. You should still be paid your normal salary, including additional duty hours. The same applies while you are breast feeding your child. You are also entitled to have privacy to breast feed your child or to express milk.

    Flexible training

    After your baby is born, you may find it easier to work part time. This is known as flexible training. You can apply to the postgraduate dean for your own job to be made part time. Alternatively, you can apply for a full time post, and you need state that you want to do this part time only after the job is offered. You have to do at least half a post, including on call. The down side is that your CCST date changes pro rata, so you may end up spending 12 years as a specialist registrar.

    The practicalities

    In practice most female trainees find it hard to demand their rights and often get further by not being seen to do so. Here are some ideas.

    Taking leave

    If you are due to change jobs during maternity leave, make sure you take your full entitlement of annual leave from the first job. Most women start maternity leave as late as possible to allow maximum time off with the baby afterwards. Surgical trainees, however, may want a break from working while pregnant: it can provide a rare opportunity to study.

    It is best not to take all your annual leave attached to maternity leave. You may need a holiday a few weeks after returning to work. I would recommend a holiday during the first trimester. This is when the risk of miscarriage and teratogenesis is highest, and nausea, lethargy, urinary frequency, and mood swings can be worst.

    Practicalities of pregnancy

    The first trimester is when the ‘minor’ disorders of pregnancy are usually worst. You could tell people who might help. The rota could be worked so that you are on call only with the most experienced or sympathetic senior house officer or specialist registrar. Women often bloom in the second trimester. Patients and other staff are usually amazingly sympathetic as soon as you are visibly pregnant. In the third trimester you will get heavy, though often not as large as some distinguished male surgeons.

    Miscarriages

    US lawyers working long hours have three times the average risk of miscarriage.2 Be easy on yourself. Going back to work after a miscarriage can be very stressful.

    Tiredness

    Telephone wards rather than pop in. For orthopaedic senior house officers, making sure that the casualty officer knows how to look fractures up in a book and how useful the fracture clinic is can keep you in bed.

    Radiography

    Most of the data on teratogenesis has stemmed from the effects of the atomic bombs in Japan.

    x ray machines produce a more predictable level of hazard. Exposure beneath a lead apron is less than 1 milliseivert over nine months.3 This is lower than is currently measurable. Background radiation is 0.7-2.6 milliseiverts a year, excluding radon. The risk of severe birth defects and cancer from radiation exposure is around 0.14%against a background frequency of birth defects of 4. It would be sensible to adopt the principles of ALARA (as low as reasonably achievable), such as standing well back and possibly avoiding certain types of operations (such as intramedullary nailings), particularly during the first trimester. You are entitled to choose how you deal with the risk.

    Morning sickness

    This can occur at any time of day. It is worst in the first trimester. Often it is worsened by relative hypoglycaemia. You could keep stashes of carbohydrates in your theatre locker, on call room, pockets, drawers in clinic, etc, and perhaps some ‘quick cook’ pasta in the theatre cupboard. Avoid missing meals.

    Operating

    Most NHS operating theatres are so inefficient that there is time to relax between cases. Orthopaedics uses power tools now, and you can always get your senior house officer or specialist registrar to do the banging, suturing, positioning, etc. Many operations can be done, at least in part, sitting down.

    Anaesthetic gases

    There is retrospective data that the teratogenic, mutagenic, or carcinogenic effects of anaesthetic gases are very low or non-existent.4 However, it would be prudent to avoid some situations, at least for the first trimester. Consider avoiding recovery rooms (where the gases are breathed off), anaesthetic rooms during mask inductions, and being near the head end of children for long periods (their circuits are leakier).

    Breast feeding

    Many working mothers like to keep the late night feed, and perhaps the early morning feed, as a breast feed. It might be difficult to get the Specialist Advisory Committee to recognise your training if you invoke the rule allowing exemption from on call duties while still breast feeding. It is not easy to nip back to the residences or find a cupboard to use your expressing machine between cases. I have always found the special care baby unit very helpful. They can keep the paraphernalia in a tub of Milton for you, and you can store labelled milk in their freezer to take home later. You don't need bras with zips in (just loosen an ordinary bra strap). It takes about 25 minutes, and you can write up notes or read while expressing. You might want to tell people that you are going to another ward, as some men can't cope with the thought of breasts and suction machines even if they approve of working mothers and female surgeons.

    Politics

    I think it is best to be open about your pregnancy early. You may be surprised at who is helpful. It is politically correct to have a female trainee, and the surgical unit would prefer heaps of notice so that they can find a suitable locum. Perhaps give them provisional dates of maternity and annual leave. People love to see the baby. Taking him or her around the hospital in a pram (so everyone can have a cuddle) pays dividends when you go back to work.

    Returning to work

    This can be amazingly liberating, but you need to plan your time meticulously. The postnatal brain oedema settles with time.

    Childcare needs to be arranged early as there is often a waiting list for services. The choices are:

    • Partner or family

    • Au pair

    • Nanny (live in or live out)

    • Childminder

    • Nursery or créche

    Could you get a toddler out of the house and delivered to childcare before your 8 am ward round? Do you want someone else in your house? You need back up in case your child or carer is ill. Ad hoc arrangements often work well. Grannies might stay for your weekend on call.

    It is possible to have babies as a surgical trainee. The physical problems of pregnancy are surmountable. The first trimester, when most people do not know that you are pregnant, is the worst, and the riskiest. With organisation, having a family and working full time or part time is achievable and enjoyable.

    Further information

    Women in surgical training at the Royal College of Surgeons (tel: 0171 405 3474) http://www.rcseng.ac.uk/public/training/women_st.htm

    Further reading

    Kelleher C. Choosing childcare. BMJ 1998; 317: Saturday 28 November 1998 http://classified.bmj.com/careerfocus/7171cf.htm

    Cassell J. Returning to work after maternity leave. BMJ 1998;316: Saturday 2 May 1998 http://classified.bmj.com/careerfocus/7141cf.htm

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