My name is Sally Foster Chang. I am a nurse practitioner. I graduated from Stanford University with a degree in human biology. I have a master's from the University of Pennsylvania in primary care and a doctorate from Thomas Jefferson University. I've been a nurse practitioner in occupational health for over 40 years. I've set up four occupational health programs for four different hospital systems, worked with the VA locally, regionally, and nationally, and I'm currently an occupational health nurse practitioner consultant with what is called Sigma Health Consulting, and we actually have a huge project with the VA kind of looking at their occupational health program. Anyway, but what qualifies me to do this talk? I am also an ex-labor and delivery nurse and prior certified childbirth educator, and I've actually had seven pregnancies. I have two children, two lovely daughters. For many years I wanted to be a midwife when I grew up, and then I realized I'm really a witch, and you can change the first letter, in the middle of the night, and that is really not a great quality for a nurse midwife. So I became an adult nurse practitioner so I could work during the day. So this is my conflict of interest slide. The opinions expressed in this presentation are those of the presenter and not necessarily those of any professional organization, institution, or my employer. So let me start out with the true story. Michelle was 22 years old and working for a private ambulance company as an emergency medical technician. It was her obstetrician's recommendation that she not lift over 50 pounds. As an EMT, she was regularly required to lift patients and stretchers that exceeded that weight, so she asked her employer for a temporary assignment. She noted that there were several postings for dispatcher jobs that involved sitting in an office all day. The company already had policies in place for light duty for injured EMTs, but her manager told her that those jobs were for injured EMTs and not for people that were pregnant, and her only option was to ignore her doctor's opinion or take a leave of absence for 90 days, and if she didn't come back after that, she would be fired. Michelle was rather stunned. She was six months away from her delivery date and she was looking at having to live for six months without a paycheck. She took the forced leave. Even with help from her family and some friends, she had to sell her car, give up her apartment, and she also amassed significant credit card debt paying for essentials for her son, medical bills, and repaying loans for her EMT training. In the past, this was not a particularly unusual scenario. That actually is from the spring edition of the ACLU magazine, just so you know I'm not dealing with any confidentiality issues. So the objectives of this presentation are to have a basic understanding of the major philosophical or physiological changes in pregnancy, be able to identify some of the major hazardous physical and chemical exposures during pregnancy that are known to result in adverse outcomes, understand the requirements of old and the new that went into effect in June of 2023 legislation regarding work actions related to pregnancy, childbirth, and the postpartum period, in particular the Pregnant Workers Fairness Act and the PUMP Act, and then finally list some appropriate accommodations for the pregnant or breastfeeding mother. So pregnancy is a very fascinating and complex physiologic state. It's constantly changing and puts unique stresses on the child-bearing individual. Many of these changes impact work. In the next few slides, I'm going to briefly discuss the interaction between the pregnant worker and her work. Let me start out by saying that if an individual can do their job prior to pregnancy, in most cases it's entirely reasonable to assume that she can do the same job both during and after pregnancy. Now all of us have known pregnant superwomen. Early in my nursing career, I worked on an orthopedic floor with a tiny little woman, she probably didn't weigh more than 100 pounds, who was pregnant with twins. That lady worked until two hours before she delivered, lifting, moving patients, running up and down the nursing floor, and putting us all to shame. And she delivered two normal babies on her due date. And there are people like that, okay? Others will not be that healthy and amazing, and maybe working in jobs where the physical and mental toxic exposures could indeed affect the outcome of a pregnancy. Pregnancy can lower the seizure threshold. Women with underlying seizure disorders may find the frequency of their seizures increases due to drug plasma level decline. And epileptic individuals can have successful pregnancies, but the risks of a poor outcome are much higher. These women may need enhanced folic acid supplementation, monthly monitoring of treatment levels, and amniocentesis at 16 to 18 weeks to look for neural tube defects. Women with other preexisting diseases like diabetes or lupus may need frequent doctor visits and more time during the work day to manage their conditions. They may also need more breaks for water and snacks. So there are major exceptions to what I said in the beginning, okay? But if a job entails a job hazard listed on this slide known to affect pregnancy, it makes sense to err on the side of a very healthy baby. So as early as 1984, the American Medical Association produced this table with recommendations relating to lifting and other tasks during pregnancy. They recommended some tasks be totally eliminated or limited at certain stages of pregnancy. As you can see, prolonged standing for more than four hours at a time should be avoided after 24 weeks. Climbing should be avoided after 20 to 28 weeks, and repetitive lifting of over 50 pounds is not advised after 30 weeks. Even repetitive stair climbing should probably be limited after 28 weeks. The National Institute of Occupational Safety and Health, or NIOSH, created this algorithm based on evidence. It's a bit complicated, but if the pregnant individual answers all the questions in the yellow boxes and determines her gestational stage, this offers some guidance regarding what NIOSH calls recommended weight limits, or RWLs. NIOSH has incorporated how many hours per day the pregnant woman is expected to lift in determining these recommended weight limits. The recommendations are based on relatively old research studies, as you can see indicated at the bottom, but it's important to note that both the AMA and NIOSH recommendations are based on the presence of a normal pregnancy in a basically healthy woman. So let's talk about the physiologic changes a pregnant body undergoes. There are cardiovascular changes, pulmonary, metabolic, gastrointestinal, immunologic, skin, renal, visual, psychological, and pharmacokinetic alterations. We'll discuss each of these briefly in the next couple of slides. To the right of this slide is my older daughter, my son-in-law, and their firstborn. Theirs was a totally normal pregnancy until the end when they discovered that the baby was breached and the cord was wrapped around her neck. So they ended up having to have a cesarean section. And it's always good to remember that in any pregnancy, the unexpected can occur at any time. So cardiac output is greatly increased in pregnancy. Sometimes even up to 45% above normal. Stroke volume is up. Plasma volume is up. The heart at the end of pregnancy is displaced upward and to the left. Heart sounds in a pregnant woman change as well, with the first heart sound louder, a wider physiologic split, and often a third heart sound. Pregnant women may exhibit new-onset systolic flow murmurs. There's so much going on with the heart that these are generally normal findings. However, women with underlying heart disease, major changes from baseline should be carefully evaluated. And it's also important to note at the end of a pregnancy, if you have a pregnant woman car mechanic or plumber, they may have difficulty lying supine on their back because of the risk of supine hypotension due to the pressure of the uterus on the great vessels. And she also might have difficulty squeezing into tight places or under a car. So there are significant pulmonary changes as well. Though the basal respiratory rate does not change, both tidal volume and minute volume increase dramatically. This is one of the reasons that pregnant women should be protected from respiratory toxins. They take in more toxin with each breath and metabolize it very rapidly. Functional residual volume is lower due to the upward pressure of the diaphragm from the enlarging uterus. And due to the fact that pregnant women consume oxygen at a 20% higher rate means they're much more sensitive to changes in elevation and oxygen-deficient environments. FEV1 doesn't change, but 70% of pregnant women experience dyspnea toward the end of pregnancy. And once again, if there's underlying pulmonary problems, the risks of right-sided heart failure are enhanced. The metabolic rate is greatly increased in pregnant women. I remember my husband complaining that sleeping with me when I was pregnant was like sleeping with a furnace. As a result, pregnant women are much more likely to experience heat stress, heat stroke, and dehydration. I taught a dance program for pregnant women during my second pregnancy, and the venue was not air-conditioned. Every time the temperature went above a certain level, we had to cancel class. Now, a woman's weight may increase by 25 to 35 pounds in a normal pregnancy, but some women gain more or less. For those of you who've never been pregnant, it's like carrying around a 25 or 35-pound kettle ball all day, every day. Total weight gain may depend on whether or not they maintained a healthy weight prior to pregnancy. So there's also hyperplasia of islet cells, which leads to an overall hyperinsulinemia. The lipid levels rise in response to insulin levels and estrogen. The pituitary gland enlarges, and in rare instances can compress the optic chiasm and result actually in visual field cuts bilaterally. Pregnant women's levels of cortisol also rise and may be somewhat responsible for the emotional liability that manifests in some women's pregnancies. Thyroid hormones rise because hepatic clearance is diminished. However, screening for thyroid disease in pregnancy is not recommended by the American College of Obstetrics and Gynecology. Nausea and vomiting are quite common in early pregnancy. In some women, the nausea and vomiting can persist until the 37th week of pregnancy, and this can complicate maintaining adequate nutrition and appropriate drug treatment. In addition, many women are extremely sensitive to smells. I remember in one of my pregnancies, I was working in a general internal medicine practice, and there was a retention of a tampon in a young lady, and none of the internal medicine docs had any women's health training or did not feel comfortable. So I had to go in there and remove it. So I did that, went to the bathroom, threw up, and then went back and started seeing patients again. I was so incredibly sensitive to smells, and it isn't one of my best memories. Pregnancy also changes the metabolism and clearance of drugs, and so pharmacologic treatment in pregnant women must be managed with great care. So pregnancy is a state of glomerular hyperfiltration, which increases by 50% by the end of pregnancy. Plasma volume is up, and renal plasmal flow is increased, resulting in a drop in creatinine. Frequency and urgency are quite common, as is glucosuria. Spilling some glucose in urine may be normal for some pregnant women, but should always be evaluated to ensure that the woman is not experiencing gestational diabetes. Gestational diabetes can result in a very large baby, over 10 pounds, fetal compromise, and is associated with a higher risk of diabetes later in life. Diabetic pregnant patients must be watched carefully and have their sugar tightly controlled to prevent complications for both the mother and the baby. In any event, it's important that pregnant women have ready access to toilet facilities, as urinary retention can also result in urinary tract infection. And this is particularly true of women that have pre-existing diabetes or develop gestational diabetes during pregnancy. So I was curious what OSHA says about required location for sanitary bathroom facilities, so I looked it up. As far as I know, there's only one memorandum from 1998 based on evidence that urinary retention can result in urinary tract infection in low birth weight babies that prescribes a clean bathroom facility should be within one quarter mile from the work location. Medical studies also indicate that women void more than men, but I don't know if that little statistic changes as men age and their prostates grow larger. So some of the hematologic changes due to pregnancy are once again an increase in plasma volume by 30 to 50 percent, and this means that pregnant women are probably carrying around at least an extra liter of fluid. But there's also a relative anemia of pregnancy due to hemodilution, and this hemodilution can lower drug levels of many medications, potentially affecting potency. The spleen enlarges in size by 50 percent, and the body enters a state of hypercoagulation. A serious condition that can occur during labor and delivery is disseminated intervascular coagulation, or DIC, where all the clotting factors are hyperactivated and the clotting function eventually fails, and this can result in severe hemorrhage and death. Hypercoagulation also contributes to the higher risk of thromboembolism during pregnancy, and pregnant women should actually get up and move around at least once an hour, or at least every two hours at the most, to avoid venous stasis. So when I started working in, oops, okay, what happened? There we go. When I started out in labor and delivery a long, long time ago, it was believed that during pregnancy a woman's immune system was significantly compromised to avoid rejection of the fetus, and that's no longer believed to be true. There is apparently a very complex immune response that changes throughout the progress of a pregnancy. Though certain immune cells functions at the level of the placenta may be suppressed to prevent rejection of the fetus, this is not true overall. However, it's also known that susceptibility to certain infections can be enhanced, and some infections are generally more severe during pregnancy. The increased risk of pneumonia, which previously was thought to be due to this suppressed immune system, is now thought to be related to the decrease in lung residual volume. During pregnancy, some autoimmune diseases worsen, like SLE, and some improve temporarily, like RA and multiple sclerosis, and this is most likely due to alterations in concentrations of certain types of T cells, B cells, cytokinins, and interferons. Now, this slide lists examples of diseases that pregnant women may be more susceptible to, some which might be more severe in pregnant women, and some infections that pose a danger to the fetus. Now, many pregnant women develop an extreme sense of protectiveness for their fetus almost as soon as they realize that they are pregnant, and I remember working in labor and delivery during my first pregnancy, and one night I was assigned to a patient with an active shingles infection. Even though I knew, rationally, that I had a very high varicella titer due to a severe chickenpox infection as a child, I asked the head nurse if I could be assigned to that patient. As I walked into the room of my new patient, I heard the resident say to her, and when did you have this cytomegalovirus infection? So, as a pregnant woman, one sees hazards everywhere. So the skin also changes. 90% of pregnant women experience skin changes. There may be a worsening or clearing of acne, an increase in sebum production, or hair growth in new areas. These changes, in addition to a change in the contours of the face and the increase in fluid load, may make being fit for and wearing a respirator quite problematic. 70% of women experience an increase in skin pigmentation, which is worsened by sun exposure. There's a condition called melasma, which results in a variegated, dark skin pattern on the face, and this condition could persist after pregnancy, especially if a woman's job involves outdoor work. Pregnant women who work outdoors should be counseled to wear sunscreen at all times. Pregnancy-related edema is common, as are the development of varicose veins and striae gravidarum, which are stretch marks. Now, visual changes in pregnancy are usually mild, transient, and don't require treatment. On the other hand, these changes could be severe, permanent, and require treatment. Glaucoma worsens in pregnancy because of the increase in interocular pressures. The cornea thickens and becomes more sensitive. As the eyeballs swell with the increase in body fluid, pregnant women may notice refraction differences and may not be able to continue wearing their contact lenses late in pregnancy, and this might be an issue for jobs that require superior visual acuity and could contribute to an increase in trips, slips, and falls. Occasionally, as already mentioned, the enlarging pituitary gland can compress the optic chiasm and result in visual field cuts, and this could be an issue for commercial motor vehicle operators and individuals working in other transportation and safety-sensitive jobs. So sometimes vision needs to be monitored in pregnancy. So pregnant women have a plethora of musculoskeletal complaints. Fifty percent of pregnant women experience low back pain from increased lordosis resulting from this enlarging uterus. In addition, neck and upper back pain can result from engorged breasts and the need to hyperextend the neck with increasing lordosis. Joint pain and joint laxity due to progesterone and the release of relaxin, an adaptation to allow the delivery of a baby through the birth canal, is expected even in a normal pregnancy. The muscles, bones, and joints are carrying this 25 to 35 extra pounds of weight every day, and strains are more likely. Peripheral neuropathies, including carpal tunnel syndrome, can occur due to edema, a direct result of the increase in plasma volume. I have very narrow wrists, and I could tell I was pregnant every single time because the first symptom I got was carpal tunnel syndrome. So let's see, moving right along. Pelvic pain at a point in pregnancy is almost to be expected, and unfortunately, the treatment of these conditions is very complicated due to issues with pain medication and teratogenic concerns. Aspirin and non-steroidal anti-inflammatories may increase the risk of bleeding in pregnancy, and there are even some concerns about the use of acetaminophen and associated neurologic complications, although more recent research is kind of pooh-poohing that idea. So pregnancy can also be a time of significant emotional and psychological growth. I have known women who felt more productive, more creative, and more energetic than any other time in their lives. As a basic type A myself, I loved being pregnant, because even when I was sitting still, I was doing something very important. However, psychological ambivalence is quite common, even among people who planned the pregnancy and look forward to parenthood. Pregnancy alters body image. I remember looking in a clothing store and wondering if I'd ever have a waist again. The massive neuroendocrine fluctuations of pregnancy can have both positive and negative effects. Emotional liability is a hallmark of pregnancy, as is fear of the unknown and feelings of profound vulnerability. Extreme stress and anxiety, whether it be related to work, family issues, financial problems, or marital discord is known to have deleterious effects on the fetus. So be liberal with your use of EAP referrals with your pregnant patients when indicated. Finally, a word about the pharmacologic considerations in pregnancy. Most pregnant women have traditionally been excluded from clinical trials. Results and dosage levels determined from studies with non-pregnant individuals cannot be generalized to the pregnant patient. Nausea and vomiting can affect these levels. Some drugs are metabolized more rapidly and some end up with longer half-lives. Keep in mind you're prescribing medications for two. And in terms of birth defects, the timing of a drug exposure is paramount. I kind of make it a habit to check with an OBGYN before I prescribe for a pregnant woman. So just quickly summarizing all these things, keep in mind the following. Body levels of toxins are higher at lower levels of exposure. So OSHA and NIOSH RELs and PELs may not be relevant. Personal protective equipment doesn't always protect both the mother and the fetus, okay? Hearing protection, you have to understand that the amniotic fluid only takes care of about 20 decibels. So that fetus could be exposed to high levels of noise even if you have the mom protected. And there was a massive study in Sweden and they have really good records on their pregnant women that in fact women that were exposed to high noise during pregnancy that their fetuses were affected as well. Pregnant women may be more susceptible to certain diseases. The shift in center of gravity affects balance and increases the risk of slip, trips, and falls. Metabolic changes affect blood levels, hormone levels, medication levels, and clearance rates. Renal changes increase the risk of urinary tract infection, kidney infections, and make voiding frequently important. Joint laxity contributes to slip, trips, and falls. Muscle and neurologic problems at work. And visual changes may or may not affect work but an alteration in vision also contributes to slip, trips, and falls and could endanger others if the pregnant woman is expected to have superior visual capacity in a particular job like a histologist or air traffic controller or driver or police officer, et cetera. So now we're gonna switch gears and go into what you actually probably came here for. Knowing the law is important in occupational health because suits relating to pregnancy discrimination are one of the fastest growing legal disputes today. The U.S. has a long history of pregnancy discrimination. In 1908, women could work no longer than 10 hours a day because they also had to fulfill their maternal duties. Men were allowed to work longer. Up until about 1970, pregnant teachers were not hired or were not allowed to work when they began to show because children might be distracted by the visual signs of pregnancy. They were also not able to work in what were considered high-risk jobs. In 1974, exclusion of pregnant women from the disability system was deemed non-discriminatory in California. It was not until 1978 with the passage of the Pregnancy Discrimination Act as an amendment to the Civil Rights Act of 1964 that pregnant women had rights to the same pay, same leave, and same general protections as any other employee with a disability. In 2002, California extended unemployment benefits to parents taking leave for pregnancy or childbirth. And in 2014, the Pregnancy Discrimination Act was amended to cover the entire childbearing couple. In 2015, the opportunity for accommodation was open to all, including women, if they were a qualified individual and had a specific disability. But pregnancy itself was not considered a disability. So pre-2023, this is also my daughter and her husband, there were a number of laws relevant to the pregnant worker. I won't go into detail on all of these because if you've worked in occupational health for any time at all, you'll know more than the average clinician about all these laws. However, before this year, pregnant women still had to prove they had a disability in order to qualify for reasonable accommodation or pre-delivery leave under the Family Medical Leave Act. Now, this slide summarizes the requirements of the Pregnancy Discrimination Act as amended in 2014. Generally, job actions cannot be based on the presence or possibility of pregnancy, and both members of the childbearing couple are offered the same benefits, other than those related to pregnancy delivery and recovery. Keep in mind that almost all countries around the world offer some type of paid leave following the birth of a child. The United States is one of the only developed countries that does not federally mandate paid leave for pregnancy, although some states do. A recent study in obstetrics and gynecology linked paid leave with higher rates of breastfeeding and lower rates of postpartum depression. My daughter works for Dan and Yogurt, a French company, and they gave her six months of paid leave after the birth of each of her children. They shut off her email and did not bother her the entire time. She is now a senior director with Dan and Yogurt. When she returned to work, she managed the logistics of importing European baby formula to ease the U.S. shortage. It involved working with the White House on policy and tariff laws, the loading and scheduling of U.S. Air Force jets, finding the proper storage facilities, and overseeing distribution in the U.S. They had a pretty motivated worker there. I don't know too many other pregnant women that had such a positive experience, including myself. In 2023, a step forward for moms working for U.S. companies occurred with the passage of two laws, the Pregnant Worker Fairness Act, and the PUMP Act, or Providing Urgent Maternal Protections for Nursing Mothers Act. Both were signed into law in December 2022 as part of the Omnibus Spending Bill. So what does the Pregnant Worker Fairness Act offer pregnant women? The PWFA prohibits employment practices that directly or indirectly discriminate against a worker who is affected by pregnancy, delivery, or what are called pregnancy-related medical conditions. We'll talk about those a bit later. It prohibits requiring the worker to accept an accommodation that was not subject to the interactive process, and prohibits denying employment based on the need for a reasonable accommodation. I don't know of any lawsuits yet, but I suspect this law either already applies to fathers and domestic partners, or it will in the near future. The PWFA also prohibits requiring the employee to take paid or unpaid leave if another accommodation is available, and it's unlawful to take an adverse action against the qualified employee. You can't change the terms of their employment, you can't demote them, you can't terminate them because of the employee's reasonable accommodation. The PWFA also prohibits retaliation for needing, requesting, or using an accommodation. An employee cannot be forced to accept an accommodation the employee doesn't want or need. They can't be forced to take leave, they can't be forced to accept a reduced work schedule, and they can't be told they have to stop traveling for work if they don't want to do that. So workers now have the freedom to choose So workers now have the freedom to request accommodation for a wide variety of pregnancy-related conditions, and do not need to prove that they have a disability to be accommodated. This is a major legal change. We'll talk about a number of pregnancy-related conditions in the next few slides. Employers cannot require any special language in the reasonable accommodation request. They have to respond to the reasonable accommodation request immediately, and even if the worker cannot do all the essential functions of their position, they are eligible to receive a temporary reasonable accommodation throughout the childbearing process. The PWFA applies to federal employees, employers in the private sector, and in companies that have 15 or more employees, full and part-time workers, seasonal workers, temporary workers, and job applicants. Now, I'm sure some of us are groaning and thinking about the workers in your facility that might take advantage of these new laws in ways that seem out of control. But keep in mind, some pregnant women, probably the majority, won't need or ask for any accommodations. On the other hand, I'm aware of a situation where a pregnant woman got pregnant and then just sort of stopped showing up at work, didn't call in, didn't do this, started out by taking long breaks, used all of her leave, et cetera, et cetera, and continued to be any absent without any accrued leave time and refused to lift anything. The providers were beside themselves because they didn't have any support staff and she didn't really even officially tell her employer she was pregnant. But someone at the facility knew she was pregnant early on and her boss and human resources had no idea what to do because it was right after this law passed. The individuals, you know, so she interpreted the law to mean basically she could do anything she wanted and still have a job. I'm not quite sure that this company can do anything about that now, but I would tell you that it's important to establish really clear company policy. Everyone should be subjected to the same requirements for calling into work when you're gonna be absent and to help the office cover if there's an issue. So, but that should be laid out very, very early. The minute somebody finds out that somebody's pregnant, this is something should be part of your new employee orientation, et cetera, et cetera, et cetera, because when you get into trouble is when you handle people differently. You know, if everyone who doesn't call in when they don't show up at work is in trouble, then the pregnant woman should be in trouble when she doesn't call into work. I mean, it's that kind of thing. So, the other thing is that they need to, they're still employees and they still need to abide by company policy. So that when a woman is found to be pregnant or releases it to her employee, their rights should be reviewed and expectations should be very clearly set to maintain adequate productivity. Communication is key. This is a situation where a formal interactive process is essential and the pregnant woman must continue to communicate with the employer when she's gonna miss work or can't handle certain aspects of her job. And all of these discussions should be documented. You don't ever want to have an employee accuse you of not having an interactive process. Now, but, you know, as I said, as an occupational health person, this is just one more little situation that is complicated and difficult to deal with. But uniform federal protections can lead to better clarity in HR offices, less turnover, boosts in employee morale, and improved public relations, all of which can decrease costs and keep a business running well. Now, the second piece of legislation related to childbearing to become effective in, that became effective in 2023 was the PUMP Act or the Providing Urgent Maternal Protections for Nursing Mothers Act. Nursing mothers are now guaranteed reasonable break time to express milk for their newborn. And the timing of these breaks must meet the needs of the mother and the baby rather than the desires of the employer. The employer must provide a place to store the breast milk. The law will not apply to the airlines, commercial motor carriers, or rail employees until at least 2025. And airlines might not even be included then. And this may be seen. Undue hardship exemptions may still apply. And this may be why the industries above were not included in the original legislation. The pumping stations supplied by the employer must be not a bathroom, sanitary, have sanitary appropriate storage facilities for breast milk. There must be a place to sit. There must be a flat surface for the breast pump. There must be an electrical outlet. There must be a private bathroom. And the bathroom must be separated from view. So it has to be private. I breastfed both of my daughters and I would have appreciated such a place. The bathroom wasn't private enough and I constantly worried about the contamination of the breast milk. So let's move on to the most important part of this presentation. What kind of accommodation for the childbearing employee are reasonable? The decision of the employer may depend on what kind of industry, how many other people do the same or similar job, how long the accommodations will last and whether or not the accommodation will extend through the postpartum period and whether undue hardship is an issue. Every situation is unique. And every request and situation are legally subject to the interactive process. So general accommodations for a typical pregnancy are listed here. Extra breaks for rest, snacks, water and bathroom use. New uniforms as the body size changes. Changes to job duties or work location to reduce bending, lifting, climbing, walking or prolonged standing. And this might even be a temporary change to a different parking place at the organization. Ability to drink water and eat during the workday. Schedule changes or excusal from absence and tardiness policies. Time off for prenatal care. Leave prior to childbirth and six to eight weeks after birth. Now depending on the industry, there may be more toxic or hazardous conditions the pregnant woman will want to request accommodations to avoid. Listed here are possible accommodations to prevent toxic exposures, heavy lifting, extremes of temperature, long work hours, rapidly rotating shifts or increased risks of slip, trips and falls. Remember the employer cannot insist the childbearing individual accept a particular accommodation, but these are suggestions for accommodations that can be brought up in the interactive process. Industries with high toxicity risks are agriculture, pesticides and extremes of temperature, manufacturing, heavy metals and solvents, beauty parlors, dry cleaning establishments, and custodial and cleaning services, where exposure to solvents and other hazardous chemicals are quite common, and health care, with possible exposure to hazardous drugs, infections, heavy lifting, and radiation. Now I'm going to go through the next couple of slides fairly quickly. Listed here are fairly common pregnancy-related conditions and possible accommodations. Things like pregnancy-related anemia, an increased risk of gallstones, migraines, DVTs, edema, dyspnea, carpal tunnel syndrome, fatigue, and reflux are extremely common. Listed also are some reasonable accommodations. This table and the four to follow were adapted from the website www.pregnantatwork.org. Hemoemesis gravidarum is also very common. I remember my second normal pregnancy, I was vomiting so much that I couldn't catch my breath, and I was afraid I was going to choke. I called a friend to have her sit with me so she could call an ambulance if I did choke and aspirate. The pregnant woman may develop gestational diabetes with an increased risk of hypoglycemia and hyperglycemia. You may be dealing with a high-risk pregnancy or something as simple as hemorrhoids. You may encounter a woman at high risk of preeclampsia or one exhibiting interuterine growth retardation. Preeclampsia, which is also called toxemia of pregnancy, develops after 20 weeks of pregnancy and is characterized by high blood pressure and severe proteinuria. Peripheral edema is part of this syndrome, but this is hard to distinguish from edema associated with a normal pregnancy. Preeclampsia can lead to hypertensive crisis, renal function compromise, liver failure, seizures, and death. But 60% of the deaths due to preeclampsia can be prevented by early recognition and intervention. Now, your pregnant woman may be suffering from a number of musculoskeletal disorders. Lower back pain occurs in more than half. Most affected musculoskeletal structures are the pubic symphysis and the sacroiliac joints. Non-inflammatory causes of back pain resulting from bone marrow edema are difficult to differentiate on X-ray from axial spondyloarthritis. The individual may be pregnant with twins or even triplets, and she may be experiencing, and I'm going to attempt to say this, oogogohydranomos, which is a low level of amniotic fluid for gestational age, or have abnormal bleeding or a low-lying placenta. She may have an incompetent cervix and may be at risk of preterm delivery, or she may be struggling psychologically. As mentioned earlier, there are infections that tend to be worse in pregnancy and put the fetus at risk. Or the pregnant woman may have any of these pregnancy-related conditions. With my first pregnancy, I was working in a very busy labor and delivery unit, and we had 16 deliveries on one shift. I didn't take a break to eat because we were so busy, and I literally passed out from low blood sugar. I actually made things worse for myself by trying to be a superwoman. So this list is in no way exhaustive, but just gives you an idea of what the pregnant person may have to deal with. Our job is to support the pregnant worker and the childbearing couple while acting as a consultant to employers to prevent legal liability and maintain workforce capacity. Having happy, healthy childbearing employees and healthy babies bodes well in the long run toward all of the above. Now, before we leave this subject, I'd just like to point out one more role for the occupational health professional, and that is to act as a consultant to the primary care providers that are writing work notes for their pregnant patients. Listed on this slide is what we can tell primary care providers about writing these notes, and we've all gotten notes that say, no exposures to any toxin, no lifting, okay? These phrases will not assist in developing a workable, reasonable accommodation. At the same website I shared before, www.pregnantatwork.org, there's a handout that can be shared with primary providers to assist them in writing duty status notes for their pregnant patients. In addition, there's a link in the resources section of this presentation, which I think is available as a handout, to a work accommodations note tool that can be shared with primary providers. It provides language and a structure for work accommodation medical notes. Now, here are the references that I used for this presentation. Here are some more, and some more, and the resources that I mentioned. And finally, this is my other daughter, my second daughter with her son, and I want to thank you for your attention. And if there are any questions, please step up to the microphone. But this is what we're working toward, a nice, healthy baby. Yes, sir? I really enjoyed your presentation. Is this on? I believe it is, yeah. Just you may have to pull it up or put it down. Yeah, I actually presented a similar presentation in this conference about four years ago, but I really enjoyed this one. I have a question about accommodation. I was a civilian Navy medical officer for several years on a Navy base, and my job was to evaluate the pregnant sailors and review something called the Industrial Hygiene Survey of where they were at and see if there's any hazards. Now, obviously, that's military sector. I actually work for a hospital-based OCMED system now, which is not military, and HR says let us know if they're pregnant so we can accommodate. They don't have the expertise of an industrial hygiene or survey. How does the HR people know that that department is safe? You know, I'm trying to figure out. Well, they don't. Yeah, what is best practice? Yeah, you know, every hospital should have a hazard analysis at least once a year, and if you can get a hold of that, sometimes they have to get a consultant in to do that. It is sort of a requirement that there's an analysis of the hazards in the workplace. I was the first occupational health person at Bryn Mawr Hospital back in 1989, and we didn't have a safety person, and you better believe I learned everything there was to know about PELs and RELs and the hazards, et cetera, et cetera, because I was basically the local expert on all those things. They eventually realized that one person couldn't manage all that, and they hired a safety officer to do that kind of thing. So, and I, you know, I just made a lot of noise is all I can say. Yes? Thank you, Dr. Joe Mignone. Great presentation, good information. I'm curious, two related questions. If a pregnant woman goes through the interactive process, and they come to an agreement on accommodations, and she at some point refuses those accommodations, and something happens, an adverse event, and there's, you know, the fetus dies or something like that, is the employer liable, and is that scenario any different with a non-pregnant employee? You know, I can't tell you exactly, because every legal situation is handled differently, but you have the Johnson Controls decision that you can't, you know, you can't make somebody take themselves out of a hazardous condition. I would say the best way to proceed on all of these is to treat all your employees the same, you know, and you can't force anybody to do anything, but document, document, document, document, because when that goes to court, because you know it's going to, if you have followed every single step, you have a very clear policy, and you have followed every single step, and she goes in there anyway, that may be your only protection. Yes, so in your experience, are those scenarios different, pregnant versus non-pregnant, from a liability perspective? In my experience, pregnant women are more likely to take any accommodation they can get, because there's, you know, they feel vulnerable, okay, so I don't think it's as big a problem, but if it involves, I mean, I don't think at this point you can cut somebody's salary, and the Johnson Controls case was they were going to cut her salary if she wasn't working in that high-risk situation, so I don't think that's going to be legal, but that may have to be decided in terms of case law down the line. Okay. This is a great presentation. Thank you. I just wanted to know if you had your, you know, the pulse of, we're talking about pregnancy, what about women undergoing IVF and the time to take off for that? It's completely included. It has to do with pregnancy. It's a pregnancy-related condition, so I can't imagine how they could not include it. That's a very good question, and I'll see if there's any, you know, resources on that. Super presentation. Thank you so much. So my question is around a disagreement that you might have as the occupational health professional with the recommendation of the treating OB-GYN, and, you know, we see this across the board when treating physicians write recommendations for certain types of accommodations or even for STD, LTD. So if you disagree with the OB-GYN's recommendation, what do you recommend? So, for example, if an OB-GYN says that a particular patient needs to work remotely for the duration of their pregnancy and you don't think that that is clinically reasonable? Well, as an occupational health person, I would probably call the OB-GYN and say, tell me why this is important. Tell me why this is necessary. You know, and I've done a lot of education of primary care providers and people like that, and, you know, I said, you know, this is our company policy. You know, we don't have, her job isn't possibly done remotely. And, you know, she has a potential of maybe losing her job if she can't do her job. And then they kind of come around and say, okay. But the other thing you want to insist on is that it's time, any note is time limited. And there isn't a reevaluation in a reasonable amount of time. Okay. So even, you know, and the thing is, lots of docs will write these notes. It basically could cause somebody to lose their job. And when the docs realize that that's what their note is going to do, they're going to backpedal a little bit. Okay. Good morning. Good morning. Thank you for the presentation. I have a question with respect to pre-placement medical. So the background is there is a large auto manufacturer. The type of job is people are on production line. They're working with their hands a lot. They're standing for most of their shifts. They don't have an opportunity to take breaks because it's on a production line. We have a declared pregnancy and a pre-placement candidate. The question is, how do we reflect suitable accommodation over there? If we say avoid prolonged standing, avoid repetitive use of your wrists, you need breaks every two hours, you can't stand for too long, they effectively may be taken out of that production line and may not even be able to get that job. We can certainly put down avoid the potential exposures to volatile organic chemicals and isocyanates and all this other fun stuff that they're exposed to, but what about these physical restrictions that may not manifest right now, maybe several weeks from now, maybe a trimester from now? Should we be putting down the restrictions at that first pre-placement or should we just allow that to gradually evolve? Well, once again, it depends on the situation. It depends on this interactive process, which you should start the minute you know the woman is pregnant. And yeah, it can change during pregnancy. You're absolutely right, which is one of the reasons why I recommend make sure these notes come in with time duration. Now you have to realize that the toxic exposure time, the worst of it is the first trimester, and sometimes even before the woman knows she's pregnant. So if it's a toxic environment and you know she's pregnant, maybe the interactive process and the reasonable accommodation should start right away. My first job at Bryn Mawr, I had a lot of resistance to light duty or transitional duty and that kind of stuff, and so what we did is we sat our employers down, our supervisors down, and we said, okay, tell me ten things you'd love to do if you had time, and tell me ten things you'd love to do but you really don't want to do them because they're really boring or something, and let's put them into a job, and let's have a list of jobs that are reasonable accommodation jobs that somebody in this situation can do maybe for nine months or six months or three months. And so we had a whole list of these jobs that we could accommodate people to, and it kind of worked for us. So that's kind of what I would tell you to try to do, but once again, you can't force a pregnant woman to take an accommodation. She has to make a request, and she also has to bring some medical documentation. She can't just say this, that. I mean, not always, but the bottom line is there should be medical documentation, and that should be written into your policy. Well, the resources that you pointed out, those are all for tolerance restrictions. So the medical is this person is pregnant. What can they tolerate? Right. Should they be restricted from repetitive use of their wrists if they don't have any peripheral neuropathy symptoms? No, I wouldn't do that because you don't want to jump the gun. I mean, it's complicated, but all of occupational health is complicated, and I said you just kind of have to do what you can do as you go along, but it was a great question. I knew I was going to get one like that. Good morning, ma'am. Thank you for your presentation. Are you aware of any requirement for pregnant workers to notify their employer of their pregnancy? No, there is none. I mean, basically it's confidential. I mean, eventually you'll figure it out. It was a great presentation. Thank you, ma'am. I do have a similar question what the gentleman has. Do you see your employees coming, the pregnant employees coming to occupational health and asking for that kind of assistance, or it's just that do you do any sort of family packet work for them, or it's just being done by OB? Yeah, no, I would not get into that. I would have the OB do it, okay? The other thing is that, I mean, I'm trying to think what the first part of your question was. You don't want to anticipate necessarily, but I would say at your new employee orientation, you let them know what the policy is, that if they want to request a reasonable accommodation, that there's an interactive process that's required and that kind of thing. I would not get into doing their FMLA paperwork because I sort of think that's kind of a conflict of interest. And, again, at the time of pre-employment, you see some advanced pregnant patients or applicants who come through. Do you put anything on, or you just clear them? You just clear them. You just clear them and let them take it from there. Okay. Yeah. Thank you. Assuming they're healthy and whatever. Good morning. The new 2023 law states that pregnant women are not required to provide medical documentation of medical complications. Pregnancy alone is sufficient. So in the request of remote work or work from home, is there still a requirement to provide physical or medical limitations or is just pregnancy alone sufficient? Well, you know, it's kind of hard to tell. I think the company's policy should say that we have the right to ask for further information. I think that's what the policy should say. All right? I'm not an HR person, so these are kind of HR questions at this point. But the bottom line is that as occupational health people, we might want to call the OB-GYN and say, okay, what's the situation? You know, what makes sense? What are you thinking here? That kind of stuff. Basically, with the idea that you're there to help the pregnant woman negotiate the next nine months. And I think a lot of us have developed close enough relationships with our employees that they trust us to do that kind of work. Hopefully that's the case. And you can sit with your pregnant woman and say, hey, can I call your OB-GYN and see what we can do to make this work. It's going to be an interactive process from the word go. There are no hard and fast whatevers. But the more information you have from that employee, the more you can help her. So anyway, I have to thank you all so much for getting up this early. I really appreciate it. Thank you.

pregnant employees

workforce

legal requirements

accommodations

challenges

interactive process

clear communication

documentation

reasonable accommodations