Birmingham Symptom Specific Obstetric Triage System (BSOTS)

BSOTS was developed by clinicians and researchers from Birmingham Women’s Hospital and University of Birmingham. It was led by Dr Nina Johns (Consultant Obstetrician and Clinical Lead of Delivery Suite, Birmingham Women’s Hospital) and Professor Sara Kenyon (Professor of Evidence Based Maternity Care, University of Birmingham).

BSOTS is a maternity triage system, which improves the safety of mothers, babies, and the management of the department. It consists of a prompt and brief assessment (triage) of women when they present with unexpected problems or concerns, 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-rator 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 (i.e., both prompt and brief) and the algorithms (which are used to define the women’s clinical priority) cannot be changed.

BSOTS has been implemented in 38 maternity units in the UK with a further 20 in the process of implementation, and 23 awaiting training. Sunshine Hospital in Victoria, Australia are the first international maternity unit to implement BSOTS with interest from others. In all sites where BSOTS has been adopted, there is evidence of notable changes in work organisation and practices, along with a reduction in staff anxiety often associated with triage work.

Implementation is supported by the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives. BSOTS has been published in BMC Pregnancy and Childbirth 2017 and the RCM Midwives Journal 2018.

BSOTS was also awarded the Academic Health Science Network (AHSN) West Midlands Meridian Awards for Safety and Innovation in July 2019. The West Midlands AHSN supported further implementation and the moved to provide training and resources remotely on their Meridian Website in early 2021. BSOTS also won the Maternity and Midwifery Services Initiative of the Year by HSJ Patient Safety Awards, recognising their outstanding contribution to healthcare in 2020.

How did MidTECH Help?

MidTECH has been involved with BSOTS for many years through many stages of development and dissemination. Initially, MidTECH worked with the team and colleagues at UoB Enterprise to ensure that the system itself was protected. This included offering advice on how best to protect the copyright in the system and ensuring that the system was only used by other organisations under certain conditions, to ensure the system is used as intended and maintain patient safety.

Initially, the system was paper-based, and training was provided face to face with the materials provided as PDFs. If other organisations wanted to use BSOTS then a simple template licence agreement between them, BWC and UoB was put in place giving them access to the resources and including certain conditions, such as not being able to edit the core materials and algorithms involved in the system, to ensure the system was used as intended in the adoptee organisation. More recently all training and support materials are available remotely through the Meridian website, with the same simple template agreement for access. The materials are all provided free of charge to ensure the widest dissemination and uptake as possible.

Discussions also began with Clevermed surrounding the incorporation of BSOTS into their BadgerNet electronic maternity system. A licence agreement was signed with Clevermed giving them permission to develop and include BSOTS as an optional module in their system in 2020, creating a digital version of BSOTS for the first time. If another organisation, who use the BadgerNet maternity system, would like to utilise the digital version of BSOTS then they can complete a simple access agreement with BWC and UoB and this will then be used to activate that module on their BadgerNet via Clevermed. There are also plans underway for BSOTS to be included in other digital maternity systems to make the update and market access as wide as possible. Again, the additional BSOTS module in BadgerNet will be available to organisations free of charge as long as they already have BadgerNet.

MidTECH continues to be involved in all facets of this project and is working closely with UoB to progress talks with the other digital maternity system providers. With BadgerNet, these other digital systems, and the continued ability for organisations to access the original ‘paper’ system, which is now available via the West Midlands Academic Health Science Network’s innovation exchange platform, Meridian, we hope this great innovation will be available and benefitting mothers, families, and children as widely as possible as soon as possible for as long as possible. More information is available on the BSOTS Public Page .


Dr Nina Johns – Consultant Obstetrician and Clinical Lead of Delivery Suite, Birmingham Women’s Hospital:

‘BSOTS is a unique safety tool for maternity care. It provides an intuitive system to clinically prioritise care for pregnant women attending the triage department.

BSOTS enables midwives to see women promptly and confidently manage their care with clinical safety at its centre. Providing order and enhanced safety to an often busy and chaotic area of most maternity units.’

Professor Sara Kenyon – Professor of Evidence Based Maternity Care University of Birmingham

‘The recent move to having information about the system on the website BSOTS Public Page, with the training and resources available once the Terms of Use are agreed, has made BSOTS accessible to more maternity units. This is good news for pregnant and newly postnatal women as well as the clinical staff who work in triage. MidTECH and University of Birmingham Enterprise Ltd have been key to successfully supporting us with copyright, licence agreements, intellectual property.’

For more information:

If you would like more information on BSOTS and how to adopt it in your organisation, both the standard and digital versions, then please visit the Meridian website here:

Here is also a video which gives more information on BSOTS: