working during pregnancy dr sally coomber mrcgp ffom frcp consultant occupational physician the...

Working during Pregnancy

Dr Sally Coomber MRCGP FFOM FRCPConsultant Occupational Physician

The Ipswich Hospital NHS Trust

Trent Occupational MedicineAnnual Symposium

University of Nottingham 18 October 2012

Overview

Applying the biopsychosocial model to three trimesters of pregnancy

Work and what can go wrong clinicallyConsequences of low birthweight babies

Legal framework

Model risk assessment:http://www.sohas.co.uk/publications/publication18.pdf

Risk assessment..the work is of a kind which could involve risk, by reason of her condition, to the health and safety of a new or expectant mother, or to that of her baby, from any process or working conditions or physical, biological or chemical agents

Where, in the case of an individual employee, the taking of any other action the employer is required to take under the relevant statutory provisions would not avoid the risk...the employer shall, if it is reasonable to do so and would avoid such risks, alter her working conditions or hours of work

references to risk, in relation to risk from any infectious or contagious disease, are references to a level of risk at work which is in addition to the level to which a new or expectant mother may be expected to be exposed outside the workplace

The Approved Code of Practice explains:Where the risk assessment identifies risks to new and expectant mothers and these risks cannot be avoided by the preventive and protective measures taken by an employer, the employer will need to...

Working during pregnancy: BPS model

Social

Biological

Conception

8 weeks

12 weeks

1st trimester

‘Psychological tasks of pregnancy’

1. Accepting the reality of pregnancy2. Facing the consequences of being pregnant3. Coping with physical changes4. Coping with uncertainty, unpredictability5. Coping with change in role and relationships6. Managing unexpected events and ‘minor

disorders of pregnancy’

Psychological Challenges in Obs & Gynae. The clinical management. Cockburn J, Pawson ME. 2007. Springer-Verlag London.

First trimester

• Biological: embryo implantation, organ formation, physiological changes; risk of early miscarriage

• Psychological: confirmation of pregnancy, change nutrition/alcohol; mood changes; EDD established; denial?; ‘fat’?

• Social: booking of care; timing of declaration of pregnancy; expectations of behaviour; ‘precious vessel’ status of primagravida?

First trimester work and birthweight

• Am J Public Health 2009; 99(8): 1409-16• Prospective cohort in Amsterdam• N=8266 pregnant women• Outcome measures: birthweight, SGA* baby• High job strain: mean b’wt decrease 72g• Work week >32 hours: mean b’wt decrease 43g• Both factors: mean b’wt reduction 150g and

SGA baby OR=2.0 (CI 1.2, 3.2)

*SGA = small for gestational age

Miscarriage

• Pregnancy loss before 24 weeks• 1:5 risk of miscarriage• 1:100 risk recurrent (three +) miscarriages• First pregnancy miscarriage: increased risk of

complications next pregnancy• RCOG no guidance on work factors

Ref: RCOG news 2008

Miscarriage and work (1)

• Heavy lifting >15x /day: doubled relative risk• Lifting >9kg: RR 1.75• Frequent lifting >15lbs: no significant effect• Physical effort: RR 1.87• Standing >8hours/day: RR 1.32; OR 1.6• Working >40 hr/week: no significant effect

Ref: Physical and shift work in pregnancy, NHS Plus 2009

Miscarriage and work (2)

• >2 previous miscarriages, plus standing >7 hours/day: OR 4.32

• If miscarriage: ‘increased’ rate of >40 hrs/day in previous pregnancies

• Night work & 2 shift schedules, for first pregnancy: RR 4.69

• Rotating shifts: ‘increased’ risk• Fixed evening shift: OR 4.17

16 weeks

24 weeks

2nd trimester

Second trimester

Biological: fetus development; fetal movements felt; sleep-wake cycle; maternal BP may fall, sensation of SOB

Psychological: obviously pregnant; ‘blooming’; energetic; bonding

Social: antenatal checks; Down’s syndrome screening; anomaly scan; maternity leave plans; expected to work normally? maternity uniform? PPE?

‘Work’ and hypertension

• 2001 study in Cork n=933 primagravidas, no work classification. Mid-term BP monitoring

• The women who were working had the highest blood pressure readings

• Older women also tended to have higher BPs• Women in employment were almost five times as

likely to develop pre-eclampsia• There were no differences in length of pregnancy,

birthweight, or method of deliveryRef:Journal of Epidemiology and Community Health 2002

‘Minor disorders of pregnancy’

• Relevant to work:– Frequency of PU– Carpal tunnel syndrome– Sleeplessness– Tired, SOB– Softened ligaments– Pubic symphysis dysfunction– Low back pain– Ankle oedema

Third trimester

• Biological: fetal growth ++; fetus viable for premature birth; placental blood flow increases++, risks of pre-term labour, stillbirth

• Psychological: preparation for birth; anxiety; impact of tiredness; poor sleep

• Social: mat leave, air travel restriction; help from colleagues; multip. expected to continue household work? domestic violence?

Working in later pregnancy

“What should I do if my job involves physical activities?It is probably advisable to reduce these activities, particularly in the late stages of pregnancy:• lifting heavy loads• hard physical work• prolonged standing – for longer than threehours at a time• long working hours – working longer thanaround 40 hours per week”

Low birthweight, preterm delivery and work

• High physical work demands: low birthweight <2500g

• Working >40 hours/week, Shiftwork: birthweight <3000g

• Temporary work contract and preterm birth (?indirect measure of stress and anxiety)

• If 2 or more out of 4 risk factors: low birthweight OR 4.65; preterm delivery OR 5.18

The most common stressogenic events reported by women who had obstetric complications were: 1) high anxiety about the health status of the fetus2) death of a loved one3) arguments with parents or spouse4) a sharp decline in income5) job-related problems of spouse”

Stress and Pregnancy

• Makes intuitive sense• Evidence from studies vary• No consistent definition of ‘stress’

Stillbirth, perinataland neonatal death

UK rates falling since 20002009 CMACE report*:

• Stillbirth 5.2 per 1000 total births• Perinatal mortality 7.6 per 1000 total births• 10% had BMI of 35 or over• Neonatal mortality 3.2 per 1000 live births

2008 Danish study: • high psychological stress increased stillbirth rate

by 80%

*Centre for Maternal and Child Enquiries

The perils of googling ‘working during pregnancy’....

Why does birthweight matter? Impact on childhood

development

Millenium Cohort Study

19,000 children born in UK 2000-2001

Four MCS surveys at 9 months, 3, 5 and 7 years so far

Odds ratio (adjusted) for poor learning & development

Selected predictive factors for children’s learning & development

Worklessness, poverty and childhood

development

Worklessness and Poverty:

‘High Risk Pregnancy’:

• High risk mother +/- high risk fetus• Maybe less likely to be working at all?• Do OH communicate with obstetric team or

vice versa?

Summary

• Risk assessment requirements• BPS model applied in each trimester• Work and what can go wrong• Why work and low birthweight matter• Obstetricians and pregnant doctors