Birmingham Symptom specific Obstetric Triage System (BSOTS)

Lead: Prof Sara Kenyon MBE, Mrs Sophie Dann, Dr Nimarta Dharni, Dr Agnieszka Latuszynska, Prof Graeme Currie

Public contributors in ARC WM’s Maternity theme have been involved in the development, evaluation and roll-out of the maternity triage system.

Dates: 2011 – 2025.

Background:

The triage departments within maternity care have developed without standardised processes or pathways, and continue to expand in workload without appropriate organisational and clinical systems. This means that women may have to wait to be seen in the order in which they arrive (often with informal triaging based on obvious need) without clinical assessment until they are seen – this is neither safe nor effective. The need to develop system to improve safety has been identified by CQC and Health Care Safety branch [HSIB Maternity Programme Year in Review 2020/21].

The Birmingham Symptom specific Obstetric Triage system (BSOTS) was co-produced by clinicians (obstetricians and midwives) and researchers at Birmingham Women’s and Children’s NHS Foundation Trust and the University of Birmingham through CLAHRC WM and ARC WM, led by Prof Sara Kenyon MBE (University of Birmingham) in collaboration with Dr Nina Johns (BWC).

The system is based on the established triage systems used in emergency medicine and uses a uniform assessment and clinical prioritisation of the common conditions that women present with in maternity triage [Kenyon S, et al. The Design and Implementation of an Obstetric Triage System for Unscheduled Pregnancy Related Attendances: A Mixed Methods Evaluation. BMC Pregn Childbirth. 2017; 17(1):309].

BSOTS consists of a prompt and brief assessment (triage) of the women on presentation, and then a standardised way of determining the clinical urgency in which they need to be seen. Women found to have a lower clinical priority can be sat back in the waiting room, thus improving the pathway, and the standardised assessment and excellent inter-rater reliability means variation in the clinical urgency of women between midwives is minimal. The shared language between health care professionals supports clear communication. The system can be amended to personalise it to individual maternity units but the principle that the assessment is a triage (ie both prompt and brief) and the algorithms (which are used to define the women’s clinical priority) cannot be changed.

Since the launch in 2013, BSOTS has been adopted and implemented nationally across 133 units, being responsible for the triage of approximately 1.5 million women and 509,129 births annually, as well as expanding to Australia and New Zealand [Vasilevski V, et al. Evaluating the implementation of the Birmingham Symptomspecific Obstetric Triage System (BSOTS) in Australia. Women Birth. 2023; 36(3): 290-8].

BSOTS is recommended by the Royal College of Obstetricians and Gynaecologists as the national maternity triage system in the UK, and is also endorsed by the Royal College of Midwives and the Care Quality Commission.

BSOTS has received a number of awards/recognition, including from the Health Services Journal, the University of Birmingham Rose Sidgwick Award for External Engagement and Impact in the 2024 Founders’ Awards, and the University of Birmingham Impact award for Outstanding Contribution to Impact in Global Health 2025.

Policy and Practice Partners:

West Midlands AHSN. Royal College of Midwives, Royal College of Obstetrics and Gynaecologists, and national Maternity Units.

Co-Funding Partners:

Birmingham Women’s and Children’s Foundation NHS Trust (BWC) and multiple NHS implementation units.

Recent Work:

Aims and Objectives: We undertook a further study to explore the implementation, fidelity, reach, adoption and sustainability of the BSOTS maternity triage system.

Methods:

Design: A qualitative evaluation study.

Setting: Maternity units in the UK who have implemented BSOTS or are in the process of doing so.

Participant population: Midwives and obstetricians involved in the implementation of BSOTS.

Planned Measures: Planned size of sample: 1) Quantitative survey: n=91 site leads, 2) survey with maternity triage staff from selected sites, 3) qualitative interviews/focus groups: 30-40 interviews or up to 8 focus groups with maternity triage staff and BSOTS development team and regional implementation leads.

Analysis: Our evaluation will explore the implementation of BSOTS in practice using a blended approach that combines Proctor’s implementation outcomes and Normalisation Process Theory (NPT).

Main Results: 

Semi-structured interviews were carried out with 43 maternity professionals (maternity triage staff of varying levels including midwives, obstetricians and senior leaders) across nine sites representing a range of implementation experiences.

All sites had implemented BSOTS, though most reported there had been varying levels of challenges, including those were BSOTS had been reported as normalised in their sites, and those who had been implementing BSOTS for a number of years. 

Contextual factors were a key issue in influencing the implementation and sustainment of BSOTS. In sites where BSOTS had been normalised and successfully integrated into routine practice, it was organisational and leadership buy-in that helped mobilise support for other contextual factors required for implementation fidelity and success. This included establishing a clear identity of the triage department, sufficient midwife and obstetric staff levels, appropriate space, a dedicated and protected core team, and adequate equipment and resources. In order to accommodate these factors, it often meant that sites required complex system-level changes, for which strategic intentions and organisational support were integral.

Conclusions: 

This study found that successful implementation and normalisation of BSOTS was driven by contextual factors, particularly organisational buy-in and leadership support. While regulatory requirements enabled the prioritisation of triage within maternity services, our evaluation emphasised the importance of both leadership and frontline staff support for effective integration and sustainment.

Evaluation findings were used to inform an implementation toolkit for clinical triage teams seeking to implement or reinvigorate BSOTS in their sites.

Publication:

Dharni N, Latuszynska A, Dann SA, Johns N, Currie G, Kenyon S. Factors influencing normalisation and sustainment of the Birmingham Symptom-specific Obstetric Triage System (BSOTS): a qualitative implementation evaluation study with UK maternity health professionals. Implement Sci Commun. 2025; 6(1):30.

Implications for Implementation:

BSOTS has transformed the management of maternity triage nationally, and improved safety for pregnant women and their babies. We will continue our successful roll-out of this intervention at home and abroad.

BSOTS is available on BadgerNet EPR. We are also working with AllScripts, Cerner, K2, EuroKing, EPIC, and System C to integrate BSOTS into their maternity Electronic Patient Records (EPR).

Further Information:

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