Professor Sara Kenyon and her team discuss the importance of patients requiring emergency maternity services receiving care dependant on their level of need.
Back in 2013 our team of researchers from the University of Birmingham, in collaboration with Birmingham Women’s and Children’s NHS Foundation Trust, developed a maternity triage system proven to improve patient safety. The recent Care Quality Commission (CQC) findings from a national review of England's maternity services between August 2022 and December 2023, has highlighted triage as an area where not everyone received a safe and timely assessment and cites the solution as implementation of the RCOG Good Practice Paper on Maternity Triage which includes the Birmingham Symptom-specific Obstetric Triage System (BSOTS) to improve safety. This was co-authored by Professor Kenyon and Dr Johns and published in December 2023 and is a welcome endorsement of our work.
Many hospitals will have begun implementing BSOTS since their inspections as its uptake has grown exponentially in recent years. However, implementation can be complex and the CQC report highlights that “implementing the recommendations will require significant system-level change and investment, and a commitment to multidisciplinary working to improve local pathways”.
Maternity triage is the emergency portal for women and birthing people attending with unscheduled, urgent concerns related to pregnancy or following birth. Reasons to attend vary, but may include feeling baby moving less, being in labour, heavy bleeding, or having a seizure.
The CQC highlighted widespread inconsistencies across maternity triage services, particularly in prioritising care, timeliness of assessment, staffing levels, and staff training. The recent report underscores the critical need for structured and effective maternity triage systems and recommends the introduction of “an agreed national standard and reporting tool for maternity triage, similar to that used in emergency medicine” which has been developed by researchers at the University of Birmingham the Birmingham Symptom-specific Obstetric Triage System (BSOTS).
Funded by the NIHR Applied Research Collaboration (ARC) West Midlands (a project that partners higher education institutions with local NHS trusts), the researchers from University of Birmingham (led by Professor Sara Kenyon) and clinicians from Birmingham Women’s and Children’s NHS Foundation Trust (led by Dr Nina Johns) worked collaboratively to develop BSOTS.
BSOTS includes a brief, standardised assessment of the woman or birthing person within 15 minutes of arrival in triage by a midwife, to identify the reason for their attendance, perform a set of clinical observations, and assess the wellbeing of the baby. A symptom-specific algorithm is used to identify the person’s level of clinical urgency (red, orange, yellow or green), which guides their immediate ongoing care and timings of medical review. This system ensures pregnant women and birthing people attending maternity units for unscheduled, urgent concerns are assessed and treated based on clinical need, ensuring timely intervention for those who need it most.
In addition to improving safety, BSOTS enhances communication within clinical teams by providing a shared language. Standardised assessments and excellent inter-rater reliability means variation in clinical assessments between midwives is minimal and documentation is consistent. Due to the unpredictable nature of maternity triage, BSOTS enables units to manage care more effectively when there is limited space, and facilitates clear escalation when workloads become too heavy.
This structured approach has transformed maternity triage departments across the UK, enhancing the safety of both mothers and babies. Since its development in 2013, BSOTS has been implemented in 109 units, with a further 62 sites in the process of adoption, totalling 90% of UK maternity units. The system has also gained international recognition, being utilised by maternity units in Australia and New Zealand. BSOTS won the Health Service Journal’s Patient Safety Award for Maternity and Midwifery Services Initiative of the Year in 2020, and its success has been supported by endorsements from the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM). More recently, Professor Kenyon won the Rose Sidgwick Award for External Engagement and Impact at the Founders' Awards 2024 at the University of Birmingham.
The CQC highlights the importance of safety within maternity triage and the need to implement the RCOG Good Practice Paper on Maternity Triage. This provides guidance for units on the safe and effective provision of care within maternity services using a structured approach to triage and recommends implementation of BSOTS as a key solution which improves both risk assessment and safety.
For further information on BSOTS, please visit https://future.nhs.uk/BMHSymptomObstetricTriageSystem or contact bsots@contacts.bham.ac.uk.
Professor of Evidence Based Maternity Care
Profile for Sara Kenyon, Professor of Evidence Based Maternity Care, Institute of Applied Health Research, University of Birmingham.
