Systemic Policy Reform Boosts Protections for Pregnant Surgeons

The demographics of the surgical workforce continue to evolve with a growing proportion of women entering surgical specialties.

In 2025, the Association of American Medical Colleges reported that women comprised 55% of medical school matriculants and 39.2% of resident physicians in surgical specialties.¹

As the proportion of trainee and practicing female surgeons increases, pregnancy among members of the operative team will become more common.

Emerging data on pregnant surgeons have demonstrated a significant increase in obstetrical morbidity compared to nonsurgeon counterparts. Rangel and colleagues compared obstetrical outcomes between pregnant female surgeons and pregnant nonsurgeon female partners of male surgeons.² These two populations were chosen due to their sociodemographic similarities, including delayed timing of family building compared to the general population.

Miscarriage rates amongst female surgeons were as high as 42%, more than double the rate of the general population. Surgeons also were more likely to experience major pregnancy complications (e.g., pre-eclampsia, preterm birth, fetal growth restriction) compared to nonsurgeon partners, even after controlling for age, race, use of assisted reproductive technology, and work hours.²

Long operative time, defined as more than 12 cumulative hours per week, was the greatest independent risk factor for adverse pregnancy outcomes, likely due to the intense physical and mental demands associated with performing surgery.² When overall work hours were examined, a four-fold increase in risk of preterm delivery was found among physicians working more than 60 hours per week.³

Night shift and irregular shift work were also associated with increased odds of miscarriage, pre-eclampsia, and preterm delivery, likely due to sleep deprivation, higher stress levels, and the disruption of circadian rhythm.^3,4 Long working hours may increase catecholamine release, which in turn increases uterine contractility and the risk of miscarriage and preterm delivery.⁴ Despite these adverse effects, few female surgeons reduce their workload during pregnancy.²

Managing Physiologic Changes in OR

Operating while pregnant presents distinct physical challenges for surgeons. Early in pregnancy, rising β-hCG levels are commonly associated with nausea and vomiting, which may interfere with operative performance.⁵ Practical mitigation strategies include pre-operating room hydration, small frequent snacks, and the use of antiemetics when indicated.

Pregnancy-related hormonal changes also cause systemic vasodilation, particularly through the release of relaxin, the hormone that increases ligament and muscle laxity. This hormone reduces venous return, increases cardiac output, and lowers blood pressure, which typically reaches its nadir between 20 and 24 weeks of gestation.

The combination of these physiologic changes, when coupled with the physical demands of operating, increases maternal body temperature and can decrease the threshold to experience syncopal episodes.⁵ The Heart Rhythm Society recommends increasing salt and water intake, using compression stockings, and avoiding triggers like rapid positional changes to prevent syncope.⁶ The use of cooling vests during surgery is another noninvasive strategy to improve comfort and reduce syncopal risk.

Ergonomic Strategies for Pregnant Surgeons

Despite advances in surgical ergonomics, data on work-related musculoskeletal (MSK) disorders among pregnant surgeons remain limited.

To better characterize these challenges, Wang and colleagues evaluated MSK symptoms experienced by pregnant surgeons, and 94.7% of respondents reported that workplace activity exacerbated pregnancy-related MSK symptoms.⁷ Common symptoms included fatigue, back pain, leg and ankle swelling, carpal tunnel pain, hip pain, and pubic symphysis pain.⁸

Prolonged periods of standing or walking, 60-hour workweeks, 24-hour or longer shifts, overnight shifts, surgical retraction, sustained wrist flexion, lifting, use of lead aprons, and transferring/transporting patients were among the most frequently reported aggravating factors.⁷ These demands place increased physical strain on the spine, pelvis, and upper and lower extremities, particularly in the context of pregnancy-related biomechanical changes.

Pregnancy-related hormonal, physiologic, and anatomic adaptations further compound these ergonomic challenges. Elevated pregnancy hormone levels promote fluid retention and edema due to decreased venous return. Pregnant surgeons may benefit from increased use of ratcheting instruments that minimize grip force and allow for changes in hand orientation to protect the wrists.⁷

Anatomic changes during pregnancy also pose significant ergonomic challenges in the OR. The enlarging gravid abdomen increases the distance between the surgeon and the operating table, resulting in increased upper extremity strain and shoulder fatigue. In both laparoscopic and open surgeries, the use of an additional standing step may be required to prevent contact between the gravid abdomen and the OR bed or retractors.

Strategies to alleviate MSK symptoms include sitting, stretching, intraoperative breaks, use of heating pads, and back support belts.⁷ It is recommended that pregnant surgeons in the third trimester take frequent intraoperative breaks to sit or stretch, limit consecutive operating time, and minimize workplace responsibilities that require continuous standing for more than 3 hours. When necessary, coverage assistance from colleagues or co-trainees should be proactively solicited or implemented to reduce physical strain.

Specific Considerations: Highest Risk Exposures

Inhaled Toxins

A systematic review in the 1990s found that exposure to nitrous oxide among pregnant medical personnel was associated with a 1.9-fold increased relative risk of miscarriage compared to unexposed controls. Given this established association, exposure of pregnant women to anesthetic gases should be limited and total intravenous anesthesia used around pregnant staff when available.³

Chemicals found in surgical smoke are also associated with infertility, congenital defects, and miscarriage. Use of smoke evacuators to eliminate smoke from the surgical field should be prioritized in all surgeries, and N95 masks should be worn by pregnant surgeons working in cases with expected high levels of smoke generation.⁹

Radiation

Surgical subspecialists exposed to high levels of radiation should be cognizant of the specific precautions required to protect their pregnancy. The recommended lead gown thickness for pregnant women is 0.5-1 mm, compared to the standard 0.25 mm gowns. Fetal radiation dosimeters should also be worn under the lead gown at the abdominal level in all pregnant women exposed to radiation.⁹

Methyl Methacrylate (MMA)

MMA is used as a bone-cementing agent in orthopaedic surgeries and has been shown to have teratogenic effects, particularly causing skeletal abnormalities, at high exposure levels in animal studies. Although occupational exposure is far less than levels used in these studies, mixing of MMA, which incurs the highest risk of exposure, should not be performed by pregnant individuals.⁹

Chemotherapy Agents

Oncologic surgical subspecialists performing hyperthermic intraperitoneal chemotherapy (HIPEC) should ensure no pregnant staff are present in the OR following the introduction of the chemotherapy agent, which is highly teratogenic.³ Any women or men attempting to conceive within the upcoming 2-3 months, and pregnant or breastfeeding surgeons should not be exposed to these medications.

Stigma Surrounding Pregnancy

Pregnancy-related discrimination and social stigmatization are well-documented phenomena in the surgical profession.¹⁰

Among general surgery residents, 80% of nonpregnant females reported experiencing gender discrimination compared to 17% of their male counterparts. This already staggering percentage increases to 90% among pregnant general surgery residents.

Female residents cited attendings as the most likely perpetrators of gender-based discrimination pertaining to experiential opportunities and evaluations, while co-residents were the most likely source of negative reactions surrounding pregnancy and childcare. Surgical trainees who perceive stigma during childbearing also report significantly higher career dissatisfaction. Among female surgeons who gave birth during training, 40% strongly considered leaving their career and 30% discouraged female medical students from pursuing surgery due to the challenges of balancing pregnancy and training.³

With twice the rate of miscarriage compared to the general population, the psychologic devastation following pregnancy loss is an additional burden shouldered by female surgeons. Following miscarriage, 10% of women experience acute stress disorder and 25% experience post-traumatic stress disorder.³ Yet, 75% of female surgeons report taking no time off work following a miscarriage (loss <20 weeks), and 45% report taking less than 1 week off work following a stillbirth (loss >20 weeks).²

The culture of surgery often normalizes personal sacrifice while minimizing the effects of burnout. When compounded with the physical and psychosocial demands of pregnancy, pre-existing gender discrimination, and the limited protections afforded to pregnant US physicians, it is not surprising that obstetrical outcomes are worse among female surgeons.

Systemic Institutional Changes

Attending surgeons have some autonomy over their operative schedules, but surgical trainees have limited control over their work hours during residency and fellowship.⁷ When surveyed, residency program directors viewed pregnancy as an inconvenience, reporting concerns regarding education, service coverage, and hospital costs.³ Therefore, the implementation of explicit departmental policies is essential to protect surgical trainees.

A proposed example is an opt-out policy that automatically limits 24-hour shifts, overnight call, and heavily operative rotations in the final months of pregnancy.⁷ Given the unique structure of residency and fellowship programs, individualized solutions may be necessary to support pregnant trainees while minimizing additional strain on colleagues providing coverage.

Pregnant surgeons represent a distinct, high-risk occupational cohort that likely will increase in the coming years. Specific considerations should be made to ameliorate the physical burdens of performing surgery during this critical time and actively support colleagues throughout pregnancy and the postpartum period.

Disclaimers

Throughout this article, the words “women” and “female” are used when referring to pregnant and birthing individuals, acknowledging that gender and birthing status are not synonymous.

The thoughts and opinions expressed in this article are solely those of the authors and do not necessarily reflect those of the ACS.

Dr. Taylore King is a clinical fellow in complex benign gynecology/minimally invasive gynecologic surgery at the Cleveland Clinic Florida in Weston. She graduated medical school with a Distinction in Global Health from The University of Texas Southwestern Medical Center in Dallas and subsequently completed her obstetrics and gynecology residency training at Emory University in Atlanta, GA.

References

1. Association of American Medical Colleges. 2024 Report on Residents. Available at: https://www.aamc.org/data-reports/students-residents/data/report-residents/2024/executive-summary. Accessed March 5, 2026.
2. Rangel EL, Castillo-Angeles M, Easter SR, et al. Incidence of infertility and pregnancy complications in US female surgeons. JAMA Surg. 2021;156(10):905-915.
3. Glazer TA, Gunderson KA, Deroo E, et al. Providing a safe pregnancy experience for surgeons: A review. JAMA Surg. 2024;159(10):1205-1212.
4. Cai C, Vandermeer B, Khurana R, Nerenberg K, et al. The impact of occupational shift work and working hours during pregnancy on health outcomes: A systematic review and meta-analysis. Am J Obstet Gynelcol. 2019;221(6):563-576.
5. Kepley JM BK, Mohiuddin SS. Physiology, Maternal Changes. In: StatPearls. Treasure Island (FL) StatPearls Publishing. January 2025.
6. Joglar JA, Kapa S, Saarel EV, Dubin AM, et al. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm. 2023;20(10):e175-e264.
7. Wang CN, Shah M, Cerier E, Wang TN, et al. The impact of procedural activities on musculoskeletal pain experienced by pregnant surgeons. Am J Surg. 2024;227:90-95.
8. Olig E, Ranieri G, Louie M. Ergonomic considerations for unique surgeon populations. Curr Opin Obstet Gynecol. 2024;36(4):260-265.
9. Anderson M, Goldman RH. Occupational reproductive hazards for female surgeons in the operating room: A review. JAMA Surg. 2020;155(3):243-249.
10. Schlick CJR, Ellis RJ, Etkin CD, Greenberg CC, et al. Experiences of gender discrimination and sexual harassment among residents in general surgery programs across the US. JAMA Surg. 2021;156(10):942-952.