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    Oh, by the way...when do I have to quit working?

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    How many times has a patient said, “Oh, by the way, doctor…” just as you’re leaving the exam room? This column will help you quickly triage those seemingly offhand yet clinically significant encounters.

    DR. PHELAN is a Professor in the Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque. A member of the Contemporary OB/GYN Editorial Board, she is an Oral Examiner for the American Board of Obstetrics and Gynecology.

    Mary is a 26-year-old G1,P0 who is 34 weeks' pregnant with an uncomplicated, singleton gestation. She's in for a routine prenatal visit and asks, "When do I have to quit working?"

    Implicit in this patient's question are actually multiple concerns. She may really be asking you—or herself:

    1. Does working pose a danger to my pregnancy?

    2. Do I need to quit work before I deliver?

    3. Do I want to quit work before I deliver?

    4. What do I tell my employer about a start date for maternity leave?

    You need to address each of these issues in order to answer Mary's first question.

    Common-sense accommodations

    Ideally, you should have reviewed Mary's work-related duties early in her prenatal care to determine if any modifications were indicated. Few jobs require major modifications for an uncomplicated pregnancy. The main issues are avoiding heavy lifting (especially repetitive lifting of more than 25 lb), wearing shoes that minimize the risk of slipping or falling, ready access to fluids and bathroom privileges and, if a woman is working with solvents, being in a well-ventilated room. Later in pregnancy, the lifting restrictions have greater importance because the effects of relaxin and increasing lordosis can increase the risk of a lumbar strain, sciatica, or symphyseal separation, which can be difficult to treat during advanced pregnancy.

    Many women feel they need to quit work near the end of pregnancy out of concern that work will increase their risk of preeclampsia or other complications of late pregnancy. Working outside the home does not cause pregnancy-induced hypertension or preeclampsia, but it can make these conditions worse, if they do occur.

    What the law says

    Hypertensive complications would be a reason for a woman to consider working part-time rather than full-time or going on maternity leave before delivery. Under the Pregnancy Discrimination Act, such a patient might qualify for disability leave until delivery because hypertensive complications are true complications, not standard events or routine problems seen in a term pregnancy. Otherwise, a woman with an uncomplicated pregnancy can work until she goes into labor or develops an obstetric problem. Many women prefer to work until labor to maximize the amount of maternity leave they can take postpartum.

    To better answer Mary's original question, try asking her how much time she wants to take away from work. If she plans to quit work after delivering, she may want to either work as long as possible or leave with a couple of weeks to spare to "get ready" for the baby. This is a personal and financial decision and there is no medical reason to support one scenario over the other. If Mary has a limited maternity leave, she will need to optimize it relative to childbirth and postpartum care of her infant.

    Many employers have a 4-to 6-week maximum for paid maternity leave. With the costs of a new baby, fewer women may feel they can afford a longer leave, even under the provisions of the Family and Medical Leave Act (FMLA), enacted in 1993. That federal legislation mandates that covered employers provide up to 12 weeks of unpaid, job-protected leave to "eligible" employees for certain family and medical reasons. One of those reasons is birth and care of an employee's newborn child. The leave is job-protected and the employee must have worked for her employer for at least 1 year, and for 1,250 hours over the previous 12 months. Some states have expanded on the FMLA provisions to allow women additional, unpaid maternity leave. (For more information on state versus federal family and medical leave, visit http:// http://www.dol.gov/esa/programs/whd/state/fmla/index.htm.)

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    Sharon T. Phelan, MD
    Dr. Phelan is a Professor in the Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque.

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