This article will cover:
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Pre-conception considerations
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Fertility treatment
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Early pregnancy
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Mid-late pregnancy
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Maternity leave
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Fathers-to-be: Paternity & Shared leave
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Perinatal & Postpartum mental health
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Miscarriage & Pregnancy loss
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Returning to work
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LTFT
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Adoption
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Advice for supervisors/managers
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Useful links / articles
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Personal experiences
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Edits / updates / improvements?
1. Pre-conception considerations
If you are planning your pregnancy and/or parental leave in advance then you can look into picking
the most suitable jobs to help make things easier.
Consider:
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Shift patterns at different hospitals - some jobs have much less onerous work schedules than others, so these might be preferable. However, remember that they are also paid less and this will impact how much parental pay you get.
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Avoiding jobs with high radiation or cement exposure
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Commute times
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Exams: time off can help with preparation but it can also be hard to revise and manage a young family
These links may help you:
BOA advice, statement of expectations in pregnancy, maternity, shared parental or adoption leave
and returning to work, and guide for trainers:
https://www.boa.ac.uk/careers-in-t-o/parenthood-orthopaedics.html
BMA Maternity leave Checklist:
BMA your rights during and after pregnancy:
RCS: Surgery, pregnancy and parenthood:
https://www.rcseng.ac.uk/careers-in-surgery/women-in-surgery/parenthood-with-a-surgical-
career/
RCOG Working during pregnancy:
https://www.rcog.org.uk/careers-and-training/training/resources-and-support-for-trainees/advice-
and-support-for-trainees/working-during-pregnancy/
COPMED Gold guide:
https://www.copmed.org.uk/publications/gold-guide/gold-guide-10th-edition
2. Fertility treatment
There is significant emotional pressure when undergoing IVF treatment and trainees should be fully
supported during the process where possible.
Employees can use a reasonable number of days leave using annual leave or unpaid leave during the
course of the treatment or where possible to work flexibly in line with the service needs.
Any leave requested for appointments is managed in accordance with “medical appointments”
policies up until the point of pregnancy when this will then be managed in accordance with
maternity policies.
Employees must notify their Line Manager to advise them of any on-going appointments that they
will be required to take due to the treatment.
3. Early pregnancy
The earlier you feel able to tell people at work then the more access you will have to support. This
doesn’t mean telling everyone, but your TPD, supervisor and rota coordinator can help make life
easier.
It is only mandatory to inform your employer 15 weeks before your due date (or the date you plan
to start maternity leave).
Your finance team will require a Mat B1 certificate which will be given to you by your midwifery
team, usually after the 20-week scan.
There is lots of information available on how to maximise your wellbeing during early pregnancy but
a few key points:
Appointments
You are entitled to time off for any midwife appointments etc. Most antenatal services don’t do
evening or weekend appointments! Partners are entitled to unpaid time off to attend two antenatal
appointments.
Radiation
During pregnancy, there is a potential risk of radiation to the foetus. Radiation exposure if wearing a lead gown is less than 1 milliSievert over nine months, to put this in perspective the dose for a patient receiving an X-ray of the spine is 1.5 milliSievert. There is no legal obligation to use radiation during pregnancy. If you choose to continue then 0.5mm lead gowns should be worn – practically this usually means double gowning (heavy!), using an overlapping skirt, or a skirt and vest gown which covers your abdomen twice. You should also be provided with a radiation monitor to wear underneath your gown.
Read these articles about radiation in pregnancy:
https://www.hse.gov.uk/pubns/indg334.pdf
https://boneandjoint.org.uk/Article/10.1302/0301-620X.94B1.27689
Ways to further reduce your radiation dose whilst pregnant:
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Tell the radiographer you are pregnant so that they can collimate or focus the X-ray beam on
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the area of interest.
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Use the mini c arm if possible which has a smaller radiation dose.
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Get into the good habit of taking fewer X-rays
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Stand further away from the C arm, 2m away dramatically reduces the dose.
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Stand behind a portable screen in theatre.
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Hospitals usually leave it up to the pregnant individual’s preference what they want to do. The other registrars and consultants can manage to accommodate you if you don’t want to do cases involving a lot of X-rays
Cement
The feto-toxic PMMA level is unlikely to be exceeded during standard operating practice but you can ask to limit your cement exposure (e.g. only 1 cement case per day). The vapours from PMMA cement are classified as irritant. The main problem they can cause is irritation to the conjunctiva or respiratory tract. Mixing using a vacuum and using a cement gun along with the laminar flow air system all help to reduce our exposure to the vapours. There is no known evidence of risk to the foetus from these fumes but the effects have not been studied.
Most hospitals will leave it up to you if you want to do cases involving cement during pregnancy. Some people choose to continue as normal and some choose to step outside while the cement is used.
Read this systematic review on the risks of PMMA:
https://arthroplasty.biomedcentral.com/articles/10.1186/s42836-020-00059-z
Iodine
Iodine should not be used as a hand scrub during pregnancy or breastfeeding as it can impact the foetal thyroid.
Blood borne viruses
No post exposure prophylaxis is currently available to take that is safe in pregnancy. Therefore consider limiting risk by avoiding operating on high risk patients.
Manual handling
Manual handling alongside other physical aspects of the job should be considered. For example standing all day for a long spinal case may become especially difficult as your bump grows.
Anaesthetic gases
New or expectant mothers should limit their exposure to anaesthetic gases. Evidence for adverse effects of volatile anaesthetics on exposed personnel is scarce and inconsistent, but there is no evidence of adverse effects when environmental levels are kept within legal threshold values. With modern theatre ventilation and closed circuit anaesthetic machines exposure is minimal and considerably less than the WEL (Workplace Exposure Limits).
Sickness and other pregnancy symptoms
This is hugely variable between people and pregnancies. It may be necessary to adjust your working pattern to manage your symptoms which may be different at each stage of pregnancy.
Nausea:
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The standard advice for nausea during the first trimester is to eat small meals often which are quite plain e.g. crackers/toast etc to help settle the stomach.
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Strong smells can trigger the nausea, which may be unavoidable in theatre.
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Staying hydrated and well rested is also thought to reduce the severity of the nausea.
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In some cases, it may be necessary to discuss anti-sickness medication with your doctor.
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If you feel really sick it can help to unscrub for a few minutes. Clearly, if you are actively vomiting it is unwise to operate.
Feeling faint:
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Pregnancy may increase the chance of you feeling light-headed or faint. Here are some tips you can do to combat it.
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Eat regular small meals and stay hydrated
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If you feel yourself getting slightly light headed do some heal raises or move around a bit at the table to get the blood pumping back up from your legs.
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Keep a chair or stool nearby just in case you need to use it.
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If you really feel faint step back away from the table and sit down, you will desterilise yourself but clearly that is highly preferable to fainting onto the patient’s open wound and jeopardising the sterility of the operation.
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Some people find DVT stockings or maternity compression stockings helpful.
4. Mid-late pregnancy
You should be offered to come off nights and on calls from 28-weeks pregnant, or earlier if clinically indicated. You do not need to sort swaps for any on calls etc, and your pay is protected.
Maintaining good nutrition and planning for additional healthy snacks is key to getting through a working day.
Make use of breaks and sit down whenever you can.
You must obtain a MATB1 from your midwife to provide copies to your employer. This allows you to take maternity leave and claim statutory maternity pay.
Important points to remember:
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You can decide what is right for when you stop on calls or night shifts depending on how you feel.
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You are entitled to paid leave for all your maternity appointments including parenting classes.
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There is some evidence that working night shifts during pregnancy may increase the risk of premature labour.
Plan maternity leave and return to training:
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You are entitled to 12 months of Maternity Leave starting from 11 weeks before due date
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This is a good time to start planning childcare for your return to work.
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Starting maternity leave:
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You need to inform the TPD and deanery in advance of your due date, it will be helpful to them for rotation planning if you can tell them when exactly you intend to go off and how long you intend to take off.
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Maternity leave can start from 29 weeks gestation. Most people stop working at 36 weeks, but you might want to go on until 38 weeks.
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If you are due to change hospitals after 29 weeks this will affect your maternity pay arrangements. It can also be stressful to change jobs at this time in your pregnancy. It’s worth speaking to the TPD about future job arrangements as early as you feel comfortable to help make your life easier.
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If you need to take sick leave because you are unwell during your pregnancy that is not a problem however if you need to take sick leave in the last 4 weeks of pregnancy then your employer may ask you to start your maternity leave rather than take sick leave.
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It might sound like madness to be looking at nurseries before your baby is born, but especially if you are thinking of going back after 6 months, it’s important to get organised.
5. Maternity leave
You are entitled to 52 weeks maternity leave if you have 12 months continuous service for the NHS at the beginning of the 11th week before your due date (29/40), and you intend to return to work with the NHS.
This is broken down into:
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8 weeks full pay (less any SMP or MA)
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18 weeks half pay (plus and SMP or MA)
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13 weeks SMP or MA
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13 weeks unpaid
Pay is calculated based on your pay during the 8 weeks before and including the 15th weeks before
your due date, aka 18-25 weeks.
Whilst you are on mat leave any increments should still happen.
You accrue annual leave (and bank holidays) during mat leave. This is often taken at the end of mat leave, or it can also be used to create a phased return.
Keeping in Touch (KiT) Days
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KIT days can be used in a variety of ways. You can use study budget for courses etc as part of this. Bear in mind that they can only be taken during actual maternity leave, not during AL.
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Get paid for your KiT days by doing them during the unpaid part of your maternity leave. Read these two useful articles on KIT days:
https://maternityaction.org.uk/advice/keeping-in-touch-days/
https://www.boa.ac.uk/careers-in-t-o/parenthood-orthopaedics/studying-and-keeping-in-touch.html
Whilst on maternity leave you are entitled to reduced fees for GMC, ISCP, BOA etc but none of this happens automatically.
RCS provides free membership for those on parental leave (contact the membership support team).
Other useful tips:
Log into your NHS email monthly - even if you don’t look at anything in it. Otherwise they lock you out and you can’t get it back.
Add your maternity leave to ISCP: Dashboard > Training history> out of training/leave form.
Shared parental leave is an option. It is particularly worthwhile considering if you both work for the NHS.
6. Fathers-to-be: Paternity & Shared Leave
During Pregnancy:
Expectant fathers or partners are entitled, as a minimum, to unpaid time off to attend up to two ante-natal or adoption appointments. They are entitled to 6.5 hours per appointment although an employer could agree to provide more.
Paternity Leave:
Standard paternity leave is 1-2 weeks. You can choose to take either one week or two consecutive weeks of paternity leave. It cannot be taken as odd days or as two separate weeks. If you are planning parental leave then you can look into picking the most suitable jobs to help make things easier.
Consider:
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Commute times
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Specialties that are and are not important for you to lose time in
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Work schedules - some jobs are paid less and this will impact how much parental pay you
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get
Leave cannot start before the birth. It must end within 56 days of the birth (or due date if the baby is
early).
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You must give your employer 28 days’ notice if you want to change your start date.
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You do not have to give a precise date when you want to take leave. Instead, you can give a
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general time, such as the day of the birth or 1 week after the birth.
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The rules are different if you adopt:
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Claim Paternity Leave and Pay through your employer at least 15 weeks before the baby is
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due.
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You can do this by filling in the online form (previously called form SC3). Once you have completed the form, you will need to download or print it and send it to your employer:
New dads
Being a new dad can be absolutely exhausting, especially when balancing work and a new baby. Make sure you talk to your ES or a trusted colleague early if you are finding things overwhelming and just need a pause.
Shared Parental Leave
Shared Parental Leave and Pay helps eligible parents to combine work with family life. Parents can share up to 50 weeks of leave and up to 37 weeks of pay and choose to take the leave and pay in a more flexible way (each parent can take up to 3 blocks of leave, more if their employer allows, interspersed with periods of work). Eligible parents can be off work together for up to 6 months or alternatively stagger their leave and pay so that one of them is always at home with their baby in the first year. If you have qualified for statutory paternity leave and pay you are likely to also be eligible for shared
parental leave if your partner is in paid work and qualifies for maternity or adoption entitlements. It is particularly worthwhile considering if you both work for the NHS. The mother or primary adopter must take a minimum of two weeks maternity or adoption leave straight after the birth or placement of the child. Thereafter it can be shared up to a total of 52
weeks leave. RCS provides free membership for those on parental leave (contact the membership support team).
See the Return to training section below for support and advice in returning after a period of time off work.
Some useful links:
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Gov.uk Paternity Pay and Leave: https://www.gov.uk/paternity-pay-leave
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BMA paternity leave for doctors: https://www.bma.org.uk/pay-and-contracts/maternity-paternity-and-adoption/leave/paternity-leave-for-doctors
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Shared Parental leave: https://www.gov.uk/shared-parental-leave-and-pay
7. Perinatal Mental Health, Postpartum Depression
The perinatal and postpartum period is an area of high stress and anxiety for both parents with a significant proportion of parents suffering from mental health issues. It’s common to feel low postnatally, particularly if you are used to the mental stimulation of professional life.
Some advice to help alleviate these feelings:
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Getting out every day even if just for a 5min walk
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Finding local playgroups
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Meeting other mums with babies - Peanut & Mush apps can help you connect with
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local mums
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Podcasts
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Friends
4% of women suffer symptoms of PTSD / Birth trauma after delivery. Maternity units often provide individual or group sessions to discuss traumatic births and information can be provided by your midwife.
This website gives good advice about guiding you through the “first 1000 days”
8. Miscarriage and pregnancy loss
The loss of a child at any stage of pregnancy is devastating. You should prioritise yourself and receive
full support from work. All women experiencing loss are now entitled to additional paid leave (10 days) as are their partners (5 days)
More details here:
https://www.england.nhs.uk/2024/03/paid-leave-for-nhs-staff-experiencing-pregnancy-loss
You are still entitled to leave or pay if your baby is:
Stillborn from 24 weeks of pregnancy
Born alive at any point during the pregnancy
Here are a few helpful resources:
https://www.miscarriageassociation.org.uk/
9. Return To Training/Work
Every hospital will have a SuppoRTT champion who should be able to support you in any way you need. There’s more support available but you need to ask.
You need to give 28 days’ notice of your RTT date, but ideally plan this much further in advance.
The Academy of Medical Royal Colleges has “return to practice” guidance for anyone who has been away for over three months for any reason:
After C-section:
It is not believed that having a caesarian section makes it more difficult to return to work. Most people will take at least 3 months maternity leave.
At 6 weeks you are able to start heavy lifting and exercising again then at 3-4 months your core strength and stability should return to normal but of course, everyone is different.
Phased return:
You could use AL to take a day off each week to reduce intensity.
You should be supernumerary for the first 2 weeks after you return - but don’t presume that this will automatically be sorted. Check that you are supernumerary in clinic or at least reduced clinic numbers to start with.
Check you are not doing any OOH work for the first 2 weeks.
Amended duties:
If you are still breast-feeding when you return to training then night shifts might be difficult. You can discuss not doing nights to start with if that would help.
Breastfeeding / pumping:
Read this excellent article on Orthopaedics Online summarising everything you need to know:
Depending on your babies age you may want to express milk for home or nursery and feed them any time when you are off with them. Your supply should be fully established on your return to work so you should have no problems feeding them more or less and you should not become engorged. Allow a lactation break (as a guide, one 30-minute break every four hours) for expression of breastmilk, for at least one year after childbirth, and to adopt a flexible approach thereafter.
There should be somewhere in the hospital where you can safely and comfortably breastfeed or pump and store milk.
This should include: privacy, a plug socket, and a fridge to store milk.
https://www.hse.gov.uk/mothers/employer/rest-breastfeeding-at-work.htm
Supported Return to Training (SuppoRTT)
Having time out of training can be a difficult and stressful time for the trainee. For any training breaks longer than 3 months for any reason, the SuppoRTT (Supported Return to Training) programme has been set up. This flexible programme has been designed to include enhanced supervision, clinical simulation days, mentorship and coaching, resilience training, practical advice and sign posting.
https://www.hee.nhs.uk/our-work/supporting-doctors-returning-training-after-time-out
10. LTFT
Childcare is a common reason for going LTFT and it's worth considering if this would be right for you.
You need to think about it well in advance as applications must be completed 16 weeks in advance.
See our separate article on LTFT.
11. Adoption
You have rights to leave for adoption or antenatal appointments prior to birth and adoption leave postnatally (leave for surrogate parents is also counted as adoption leave).
Parental leave is also available for adoptive parents and LTFT can help achieve a balance between work and your new family.
The adoption process can be long and time intensive and you will need time away from work during the assessment phase.
If you’re adopting a child, you can get time off to attend 2 adoption appointments after you’ve been matched with a child.
You need to use form SC4 to tell your employer within 7 days of being notified of the adoption placement, and 28 days before you want paternity pay to begin.
See these useful resources:
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Adoption BOA:
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The process of adoption:
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Your legal rights when using surrogates and donors:
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Your employment rights around adoption and surrogacy:
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Support and advice on adoption:
12. Advice for Supervisors/Managers
Pregnancy whilst T+O training can be a challenging combination for trainees and the trusts where they are working, but you have the power to make things much easier. When a trainee informs you of their pregnancy the first thing to do is their risk assessment. This should be tailored to the individual, every pregnancy is different. But some of the things to cover are:
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Specific Hazards e.g. Radiation, Cement, Iodine
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Risk for blood borne virus
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Manual handling and physical aspects of the job
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Specifics for a post including unsupervised lists/clinics
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Shift patterns including on calls and nights
Adjustments to responsibilities or working pattern may be needed for sickness, fatigue or other symptoms of pregnancy that can affect a trainee’s ability to work effectively.
The pregnant trainee is entitled to paid leave for all antenatal appointments. Partners are also entitled to attend the 2 scan appointments. Trainees will decide on when to start maternity leave and how long to take based on what is
permitted for NHS staff, their pregnancy and a whole host of other factors. Ideally this will be all planned in advance and you can then support them with the planning of return to training.
This could include:
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KIT (Keeping in Touch) days
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Amended duties
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Phased return
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Working LTFT
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Breast feeding/pumping facilities
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Contacting the SuppoRTT champion for your trust
This comprehensive guide produced by the BOA can be used along with links to other information:
https://www.boa.ac.uk/careers-in-t-o/parenthood-orthopaedics.html
13. Useful links / articles:
Listen to this excellent podcast from WENTS (Women in ENT Surgery) on conception to Mat leave:
Pregnancy as a surgeon:
https://www.buzzsprout.com/1792796/episodes/12509261
Check out this Twitter feed also from WENTS:
https://x.com/ukwents/status/1489175166567522306?s=46&t=ZDW_a2lJyZdLovcvq71mcg
Listen to this MummaPod – a podcast with practical, honest advice and experience from an ortho trainee mum:
Read this article giving a good overview:
14. Personal experiences
Lara Jayatilaka, ST5 Registrar
‘It was always medicine first personal life second.
That was the theme of my life for many many years. I am sure that’s not unique to me. I always assumed when the time was right I would have children.
Unfortunately it did not work out to be as simple as that. I found myself in a situation I never imagined would be an issue for me, unexplained infertility. I struggled, I felt guilty when I had to take time off to go for hospital appointments, I felt emotionally distraught when I had to tell yet another rota coordinator that I had a failed cycle, miscarriage or chemical pregnancy. After lots and lots of deliberation and conversations with some fantastic trainers I decided to go LTFT and eventually took a year out of training to do back to back cycles to really give myself the best chance of a positive
outcome. Also towards the end of my journey ttc my cycles were abroad and I knew the stress of trying to organise time to cycle abroad would be overwhelming for me. Taking a year out was the best decision I made.
There were doctors I worked with who shared their stories with me, bosses that took the time to talk to me and a Facebook group of amazing medics ttc.
My advice to the past me, don’t wait till all the stars align there is no perfect time, talk to people, take the time you need and put your emotional well-being front and centre. You are not alone.
I write this at 3 am on my phone with my rainbow baby in one arm, phone in other. Without the decision I made, without the conversations I had and without stepping out of my identity of surgeon first everything else second she would not be here.’
Philip Brown, Post-CCT Spinal fellow
I was an F2 when, one weekend, due to premature preterm rupture of membranes my son was stillborn. After 12 years that sentence barely does justice to the awful, heartbreaking experience.
With no warning our baby was gone. I’d love to say that everyone I dealt with was amazing, I can’t. Despite progress in many areas, equality in pregnancy and its issues isn’t a thing. Yet the effects of an event can be significant for both partners. I took a day or two off, was sent home from my placement by a great supervisor who knew better than me that I needed to be at home with my partner. We were offered the chance to hold our son and have photos/hand prints made. In our pain and shock we declined fearing that it would deepen the anguish. Thankfully someone took it upon themselves to take a photo and a hand print. It was given later to my wife and we treasure it. The hospital were great and arranged a funeral for us with little fuss and no cost. I’m an atheist but I remain grateful that we did it as it helped with some of the grief.
So did talking. But that’s hard. Turns out late pregnancy loss and still birth is a lot more common than you think, but it’s not a topic that people really bring up. The hardest part, still, is running in to people you sort of know or maybe worked with even years later who ask about kids because they remember the pregnancy excitement and it’s never not awkward or painful to explain. There are a variety of groups both local and national available to help but we didn’t use them.
I found out more about the support available when we tried again. Not an easy task to embark on with our memories fresh and medical issues to deal with from the get go. My wife ended up on bed rest at home, for the best part of 4 months. I got the call to tell me there were issues and walked out of a placement and never went back. Every day we lived in expectation of a repeat of our first experience. The Deanery, my placement and my GP were brilliant. Not knowing what to do I got
myself signed off sick initially. Then after plucking up courage I contacted my TPD. I was given OOPC with very little difficulty to cover the remainder of a placement until our child arrived, worth remembering though that this is unpaid! We had family help but the BMA hardship fund is available as are other charitable foundations for doctors in need. I was able to return to training and finish CT 6 months later than planned. Non work issues of all kinds are more common than anyone in surgery let’s on. Talking to people within the structure is often the last thing any of us want to do. But there
exist systems to help and often people are willing if only they know you need them.
15. Edits / updates / improvements?
These support / welfare articles require constant updating to reflect the changing world of the modern Orthopaedic trainee.
If you have any edits / updates / improvements for this article please email them to: wins@bota.org.uk
Thank you for your support.
Original article by Robyn Brown.
Adapted for BOTA by Florence Shekleton.
Many thanks to Selina Graham, Sarah Dunkerley, Sophie Gatfield, and James Berwin for their contributions to this article.
Family Planning