February 14, 2025 • 31 mins
Maternity triage plays an essential role in providing urgent care to pregnant women, ensuring timely and appropriate responses to potentially life-threatening situations. The episode discusses the BSOTS system, its implementation, challenges, and the importance of maintaining relationships with GPs and midwives while prioritising urgent care needs.
• Overview of maternity triage and its significance
• Introduction to the Birmingham Symptom Specific Obstetric Triage System (BSOTS)
• Importance of timely assessment for maternal and fetal health
Want to know more?
https://www.rcog.org.uk/media/p13lrr3n/gpp17-final-publication-proof.pdf
https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-017-1503-5
https://www.cqc.org.uk/publications/maternity-services-2022-2024/triage
Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth.
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Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Florence (00:00):
Hello, my name's Florence.
Welcome to the OBSpod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife.
Maybe birth fascinates you, oryou're simply curious about what
exactly an obstetrician is.
You might be pregnant andpreparing for birth.
(00:21):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, the OBSpod is for you.
Episode 178, maternity Triage.
(01:00):
I thought it was about time thatI did an episode on triage.
What do I mean by triage?
Well, I looked up the OxfordDictionary definition and,
strangely enough, the firstdefinition it gives is about
sorting wool.
That actually triage wassorting out different qualities
(01:20):
of wool in the 18th century.
However, later on, seeminglyaround the time of the First
World War in the early 20thcentury, it became a medical
term for deciding whichcasualties needed the most
urgent treatment and, in actualfact, used a subverb in terms of
(01:43):
triaging out or leaving thosefor whom medical treatment was
actually not likely to besuccessful and focusing on those
where life could be saved.
So it has a battlefieldconnotation, but most people are
(02:06):
probably more familiar with theidea of triage.
When they turn up in A&E in anemergency situation you see a
nurse, usually fairly swiftlyafter you've arrived, and they
do some basic observations sopulse, blood pressure, ask what
you feel might be wrong with you, what are your symptoms, and
(02:28):
then from that decide theurgency with which you need to
be seen.
In A&E departments in the UKthe Manchester triage system is
used, which was introduced inthe late 90s and is a five-point
(02:49):
system that helps staff decidethe urgency with which patients
should be treated.
Therefore, for nearly 30 yearsthere's been something in place
in the NHS in terms of triagingacutely unwell people, but
(03:12):
interestingly not in maternity.
Not, that is, until the middleof the last decade when the team
in Birmingham developed BSOTS,standing for Birmingham Symptom
(03:33):
Specific Obstetric Triage System, bsots.
So the idea is that a womanturns up at the maternity
service, now arriving in atriage area, and is rapidly seen
(03:54):
by a midwife who does thosebasic observations pulse, blood,
blood pressure, oxygen levels,baby's heartbeat and finds out
what symptoms the woman isexperiencing and triages
(04:17):
according to urgency how quicklythe woman needs to be seen by
midwifery or medical staff forfurther treatment or tests.
The idea of introduction was tomake sure that those women who
needed urgent attention wouldget it quickly, and the system
(04:41):
categorises women into red,needing immediate medical
attention, amber, needingimmediate attention in the next
15 minutes, and yellow andfinally green.
And green is ideally seenwithin four hours.
(05:01):
Similar to the normal A&Ewaiting time is ideally seen
within four hours.
Similar to the normal A&Ewaiting time.
Well, I say normal A&E waitingtime, but that's rather gone out
of the window recently with thepressure the NHS has been under
.
So the idea of the BSOTs isthat you should have rapid
(05:25):
assessment of those women andbabies that need it, because in
obstetrics, as I've said inprevious episodes, everything is
extremely time critical.
If you have concerns about awoman's well-being or a baby's
well-being, every minute counts.
So women categorized as redneed immediate attention,
calling the team and transferredto the labour ward or theatre.
(05:48):
And women that are amber alsoneed urgent senior review by a
middle grade obstetrician orconsultant, whereas those that
are yellow or green, whilst it'sannoying to have to wait, we're
not putting their safety atrisk by doing so.
(06:12):
You might ask why we couldn'tuse the Manchester triage system
that's been in use since the90s in normal A&E, and that's
because maternity has some veryspecific different parameters,
because your physiology changesin pregnancy.
So what we consider normalblood pressure, pulse and even
(06:37):
some blood tests are actuallyabnormal for pregnancy.
They're different.
We have different referenceranges for many things and
therefore you can't just applythe same sort of triage system
because you may not pick up thewomen that are unwell.
(06:59):
The triage system has to be thetriage system has to be
maternity specific, and thesuccess of the BSOTS Birmingham
(07:32):
system meant that they foundthat the numbers of women
assessed within 15 minutes ofarrival in a maternity
department went from around 38%to 58%, and the aim is for women
to be assessed by a midwifewith those basic initial
assessments within 5 or 10minutes of arrival, which has
got to be good.
Since the introduction of thissystem in Birmingham and
numerous other organisationsadopting the BSOTS system, it
(07:56):
has become adopted as a nationalrecommendation.
The Royal College wrote a paperin December 2023 recommending
implementation of this type ofsystem across the board, and for
my own maternity unit, this wasa quality priority for last
(08:18):
year.
It sounds very straightforwardand easy to implement, but
actually one not only needs theright space in which to triage
and see women, but also theright staff.
If you look at the numbers ofwomen seen in triage in
(08:41):
maternity units, it's generallypublished that you might see
three times the number of womenthat are actually having their
babies at the hospital in anymonth, because women may attend
with worries about their baby'smovements or they may attend on
(09:03):
numerous occasions during theirpregnancy.
So triage can be immensely busy.
So to give you a feel ofactivity, last month in our
maternity unit we saw almost athousand women and the triage
(09:24):
team can see up to 50 women onour busiest day.
This is activity from a turn tounit that has around 5,000
births a year and therefore thisimplementation of a sensible
(09:45):
system for prioritising theorder in which women are seen is
very important.
Published data suggests thataround 15 to 20 percent of women
attending a maternity triagewill be amber, so we'll need
that required senior reviewwithin 15 minutes of arrival,
(10:10):
either because there's somethingwrong on their maternal
observations so, for example,raised blood pressure or rapid
pulse or respiratory rate orbecause of concerns about fetal
heart monitoring.
And if you look at the numbersof women that score red on the
(10:31):
triage system, the numbers aretiny, maybe two or three a month
.
So in this way it helps us notonly prioritize time wise the
women that really need rapidinput, but also the seniority of
(10:52):
doctor that they may see.
So we have excellent juniormembers of staff who are gp
trainees and they have excellentcore skills in recognising when
someone is unwell but theydon't have the specialist
knowledge and expertise ofmaternity care, certainly when
(11:21):
they start with us.
So they can safely see thewomen that are yellow or green
and have a longer timeframe inwhich to be seen and then
discuss with a senior colleague.
And we can hone our attentionin terms of more senior staff to
(11:45):
the red and amber women who mayneed that very timely
intervention to prevent them ortheir baby becoming very
seriously unwell very rapidly.
And it's much clearer now as aconsultant on call if someone
(12:06):
rings from triage or comesaround from triage and says they
have a woman scoring red oramber, I know I need to
immediately release someone togo and assess the situation and
see what needs to be done if Ican't go myself.
(12:36):
One of the key pieces ofpublished feedback from the
BSOTS implementation and BSOTSstudies are that staff found it
easier to communicate with oneanother about the urgency using
the colour coding system howquickly women needed to be seen
and what their concerns were.
So how does a woman turn up attriage?
(12:56):
So, coming back to our unitstats, around 78% of women
self-refer.
We also have extremely strictcriteria about which pregnant
women can and cannot be seen inthe main A&E department.
(13:22):
Pregnant women have differentsymptoms sometimes and different
physiological parameters whichare not necessarily well
understood by our emergencymedicine colleagues, and
therefore a small number ofwomen come to triage via A&E,
(13:45):
having been directed on asmaternity is a more appropriate
place for them to be seenbecause of the obstetric
expertise.
There has been a lot ofsuggestion of telephone
(14:06):
helplines and indeed in theRoyal College of Obstetricians
and Gynaecologists paper that Imentioned and I will put in the
show notes, there is also adviceabout dedicated 24-hour
telephone helpline, staffed by amidwife in a quiet place doing
nothing else, who can give herfull attention to women and give
(14:26):
advice on the phone, and thatis generally how we invite
people into the maternity unit.
We encourage them to phone thehelpline to discuss with a
midwife what the issue is andthen we can direct them as
appropriate as to whether theyneed to come in urgently to
triage or whether actually theycould wait for an appointment.
(14:49):
This makes it slightly easierfor us because we can give some
advice over the phone and we'vealso got some idea of who we're
expecting to walk through thedoor.
For example, sometimes if awoman rings up who thinks she
might be in pre-term labour, theteam will give us in the
(15:11):
neonatal unit the heads upbefore she's even entered the
building.
Some women will, of course,just appear, turn up of their
own accord.
Obviously, we have an open doorand we very much encourage
women to attend if they have anyworries.
(15:31):
Some women will be sent in bythe community midwives and some
women may possibly be sent in bytheir GP.
And that brings me to the otheraspect of triage.
Everything I've described up tonow might seem great, totally
(15:54):
standard, very good safety, andwhy wouldn't you want to do it?
But there is a flip side tothis whole triage issue in that
we're breaking up thatrelationship both with the
general practitioner, the GPs,and also potentially the
(16:18):
community midwives or midwiferyteams, because the first port of
call is starting to be thehospital, the hospital maternity
system and triage.
And there is some value in that, in that the hospital is open
24-7, it's always staffed.
(16:38):
There's always people there andif you've got a complication or
problem you don't want to besitting around waiting for an
appointment.
But it definitely breaks up thecontinuity.
Traditionally women, if theyhad more minor complications in
pregnancy, would contact theirmidwife or their midwifery team
(17:02):
and the midwife might phone themback, maybe arrange a visit or
fit them into clinic to have anappointment.
And because you've got thatcontinuity and they know that
woman and that woman knows thatmidwife, you then have the
ability to know what is a bitdifferent for that woman and how
that woman normally is, whather medical and obstetric
(17:26):
history is, and that might giveyou some pointers.
Whereas if a woman is phoning ahelpline or coming into triage,
chances are she's never met thestaff before.
They don't know her.
She doesn't know them.
And yes, we do now have digitalnotes and they can look on the
(17:48):
system and see what herappointments say and what the
history is and the interactionsshe's had with the maternity
service.
But it's not the same.
It's not relationship-basedcare, which has been very much
the basis of lots of maternitycare in the past.
(18:09):
Equally, gps certainly in mylocal area are completely now
excluded from maternity care.
It's very rare that when awoman has a difficulty in
pregnancy, she contacts her GP.
When a pregnant woman bookedher maternity care, one of the
(18:33):
first things that the midwifewould do at that first
assessment is decide what typeof care the woman was going to
receive, and one of the optionswas what was called shared care,
which was shared care with theGP.
So the woman would see themidwife for a number of
appointments and the GP for anumber of appointments.
However, this seems to havecompletely disappeared.
(18:58):
We don't have that shared carearrangement with our local GPs
anymore.
It's not their fault.
They're completely overloadedand my understanding is it's
also to do with the way the GPcontract works.
I believe that they don't havethose appointments included in
their contract anymore, but itcan mean that the GP is
(19:24):
completely out of theconversation of the care of that
woman for a period of time,which is not ideal if the GP is
someone who's very familiar withthat woman ideal if the GP is
someone who's very familiar withthat woman.
Gps may have lots of usefulinformation about the women on
(19:45):
their books, about their chronichealth conditions, if they have
them, and whilst that won'talways be important and of use,
I do feel that the emphasis onwomen self-referring to
maternity services and beingcared for by midwives and
(20:07):
obstetricians has really takenaway from that that the family
doctor had with that woman andwe're medicalising and bringing
everything into hospital.
So I was interested also when Iwas exploring this topic to
(20:31):
have a little look at what womenthink of the BSOTS system, and
there are a few small reportspublished, including one from a
hospital in Australia thatimplemented BSOTS.
That said women found itacceptable.
(20:52):
They had better communicationabout their likely waiting times
and they were more satisfiedwith that.
But I know from some women thatthey find it a very busy area.
They can be waiting for sometime.
(21:13):
They see a different team ofmidwives or doctors each time
they come and it isn'tnecessarily a great experience.
You might ask why we couldn'tuse the Manchester triage system
(21:34):
that's been in use since the90s in normal A&E and that's
because maternity has some veryspecific different parameters,
because your physiology changesin pregnancy.
So what we consider normalblood pressure, pulse and even
(21:56):
some blood tests are actuallyabnormal for pregnancy.
They're different.
We have different referenceranges for many things.
There are also importantsymptoms that in pregnancy may
be very significant that in thegeneral population might be
(22:21):
completely innocuous andtherefore you can't just apply
the same sort of triage systembecause you may not pick up the
women that are unwell.
This is why the triage systemhas to be maternity specific.
(22:50):
The other benefit for us inhaving implemented BSOTS is that
we can very clearly audit howwe're doing in terms of meeting
targets.
Are we seeing and assessingthose women in a timely way and,
if not, what were the barriersto that?
(23:11):
What were the blocks?
And there's a very clearescalation process in BSOTS.
If a woman is waiting longerthan she should be how you
escalate to the consultant oncall.
So, unlike previously, we'vegot a clear expectation of time
(23:31):
frames in which women might see,rather than an open-ended
situation.
And the CQC National Review ofMaternity Services published in
September 24 highlightedmaternity triage as a really
(23:52):
important first step for womenwith an emergency concern during
their pregnancy or theimmediate postnatal period the
first six weeks and was a safetyconcern in around a third of
CQC maternity inspectionsoverall, although they did
(24:23):
acknowledge that the RCOG paperand guidance had come out after
some of the inspections they'dhad.
So hopefully maternity triagewill be an area of rapid
improvement in the immediatefuture, do I think it's a good
system.
It definitely has some safetybenefits.
It can end up feeling a bitdisjointed and I think we need
(24:45):
to be careful about which womenare being seen in triage and
which women actually could waitfor an appointment with their
midwifery team or obstetric teamor GP.
I think some of theparticularly green women.
(25:07):
Do they really need to come tohospital?
Probably not, but there are somany things that worry women in
pregnancy.
You know you really want to bethere for those women that are
worried 24-7.
And that's definitely how weimprove safety for women and
(25:31):
babies.
But does it all need to come tothe hospital?
No, could we safely direct someof it elsewhere?
Maybe Could we do a better jobof women seeing their midwives
and GPs.
(25:51):
For some of the less urgentstuff, probably, but it's very
challenging because evensomething as simple as a urinary
tract infection, if leftuntreated, can make a woman
unwell, can risk the chance ofpreterm labour.
So it's very challenging not tosweep everything up into triage
(26:19):
and just try and make that assafe as one possibly can.
So what's my zesty bit, I think, for a woman, know that
maternity helplines and triageare there to be used.
You may have a bit of a wait ifsomething isn't urgent.
(26:43):
But if you're ever unsure abouta symptom or problem you're
having in pregnancy, it isalways better to ring your
maternity service and find out.
If you can easily get hold ofyour midwife and it doesn't seem
like an urgent thing to you,then great.
But at the end of the day, that24-hour number is your port of
(27:10):
call.
For anything you're worriedabout there's an expert who can
talk to about.
There's an expert who can talkto.
Never sit at home and worry.
We'd always rather you came andwe saw you and everything was
fine and you went away happy andreassured.
If you're a member of staff,then maybe you're very used to
(27:36):
this sort of triage, maybeyou're not, but bear in mind
that there's a reason why it'sbeen recommended.
There's good grounds for makingsure that women are seen in the
right order and those with moreurgency take priority and
(27:58):
however tempting it is whensomeone's been waiting a long
time or a longer time, to bumpthem forwards and and try and be
kind to them, actually it'sreally important that we stick
to that clinical prioritisationand only come to the women that
(28:20):
are non-urgent when all thoseare have been seen.
So it can be a bit frustratingwhen triage is busy and you've
got less, perhaps, doctorcapacity to review people.
But just keep like with anystructured tool, it's there for
(28:47):
a reason and if you stick tothat red, amber, yellow, green
you're not going to go wrong.
You're going to be safe on yourbusiest, busiest day.
Thanks for listening.
I very much hope you found thisepisode of the OBS pod
(29:07):
interesting.
If you have, it'd be fantasticif you could subscribe, rate and
review on whatever platform youfind your podcasts, as well as
recommending the OBS pod toanyone you think might find it
interesting.
There's also tons of episodesto explore in my back catalogue
(29:30):
from clinical topics, my careerand journey as an obstetrician
and life in the NHS moregenerally.
I'd like to assure women I carefor that I take confidentiality
very seriously and take greatcare not to use any patient
identifiable information unlessI have expressly asked the
(29:54):
permission of the personinvolved on that rare occasion
when it's been absolutelynecessary.
If you found this episodeinteresting and want to explore
the subject a little more deeply, don't forget to take a look at
the programme notes where I'veattached some links.
(30:15):
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episodes.
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(30:39):
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(31:05):
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Thank you for listening.
Hello, my name's Florence.
Welcome to the OBSpod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife.
Maybe birth fascinates you, oryou're simply curious about what
exactly an obstetrician is.
You might be pregnant andpreparing for birth.
(00:21):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, the OBSpod is for you.
Episode 178, maternity Triage.
(01:00):
I thought it was about time thatI did an episode on triage.
What do I mean by triage?
Well, I looked up the OxfordDictionary definition and,
strangely enough, the firstdefinition it gives is about
sorting wool.
That actually triage wassorting out different qualities
(01:20):
of wool in the 18th century.
However, later on, seeminglyaround the time of the First
World War in the early 20thcentury, it became a medical
term for deciding whichcasualties needed the most
urgent treatment and, in actualfact, used a subverb in terms of
(01:43):
triaging out or leaving thosefor whom medical treatment was
actually not likely to besuccessful and focusing on those
where life could be saved.
So it has a battlefieldconnotation, but most people are
(02:06):
probably more familiar with theidea of triage.
When they turn up in A&E in anemergency situation you see a
nurse, usually fairly swiftlyafter you've arrived, and they
do some basic observations sopulse, blood pressure, ask what
you feel might be wrong with you, what are your symptoms, and
(02:28):
then from that decide theurgency with which you need to
be seen.
In A&E departments in the UKthe Manchester triage system is
used, which was introduced inthe late 90s and is a five-point
(02:49):
system that helps staff decidethe urgency with which patients
should be treated.
Therefore, for nearly 30 yearsthere's been something in place
in the NHS in terms of triagingacutely unwell people, but
(03:12):
interestingly not in maternity.
Not, that is, until the middleof the last decade when the team
in Birmingham developed BSOTS,standing for Birmingham Symptom
(03:33):
Specific Obstetric Triage System, bsots.
So the idea is that a womanturns up at the maternity
service, now arriving in atriage area, and is rapidly seen
(03:54):
by a midwife who does thosebasic observations pulse, blood,
blood pressure, oxygen levels,baby's heartbeat and finds out
what symptoms the woman isexperiencing and triages
(04:17):
according to urgency how quicklythe woman needs to be seen by
midwifery or medical staff forfurther treatment or tests.
The idea of introduction was tomake sure that those women who
needed urgent attention wouldget it quickly, and the system
(04:41):
categorises women into red,needing immediate medical
attention, amber, needingimmediate attention in the next
15 minutes, and yellow andfinally green.
And green is ideally seenwithin four hours.
(05:01):
Similar to the normal A&Ewaiting time is ideally seen
within four hours.
Similar to the normal A&Ewaiting time.
Well, I say normal A&E waitingtime, but that's rather gone out
of the window recently with thepressure the NHS has been under
.
So the idea of the BSOTs isthat you should have rapid
(05:25):
assessment of those women andbabies that need it, because in
obstetrics, as I've said inprevious episodes, everything is
extremely time critical.
If you have concerns about awoman's well-being or a baby's
well-being, every minute counts.
So women categorized as redneed immediate attention,
calling the team and transferredto the labour ward or theatre.
(05:48):
And women that are amber alsoneed urgent senior review by a
middle grade obstetrician orconsultant, whereas those that
are yellow or green, whilst it'sannoying to have to wait, we're
not putting their safety atrisk by doing so.
(06:12):
You might ask why we couldn'tuse the Manchester triage system
that's been in use since the90s in normal A&E, and that's
because maternity has some veryspecific different parameters,
because your physiology changesin pregnancy.
So what we consider normalblood pressure, pulse and even
(06:37):
some blood tests are actuallyabnormal for pregnancy.
They're different.
We have different referenceranges for many things and
therefore you can't just applythe same sort of triage system
because you may not pick up thewomen that are unwell.
(06:59):
The triage system has to be thetriage system has to be
maternity specific, and thesuccess of the BSOTS Birmingham
(07:32):
system meant that they foundthat the numbers of women
assessed within 15 minutes ofarrival in a maternity
department went from around 38%to 58%, and the aim is for women
to be assessed by a midwifewith those basic initial
assessments within 5 or 10minutes of arrival, which has
got to be good.
Since the introduction of thissystem in Birmingham and
numerous other organisationsadopting the BSOTS system, it
(07:56):
has become adopted as a nationalrecommendation.
The Royal College wrote a paperin December 2023 recommending
implementation of this type ofsystem across the board, and for
my own maternity unit, this wasa quality priority for last
(08:18):
year.
It sounds very straightforwardand easy to implement, but
actually one not only needs theright space in which to triage
and see women, but also theright staff.
If you look at the numbers ofwomen seen in triage in
(08:41):
maternity units, it's generallypublished that you might see
three times the number of womenthat are actually having their
babies at the hospital in anymonth, because women may attend
with worries about their baby'smovements or they may attend on
(09:03):
numerous occasions during theirpregnancy.
So triage can be immensely busy.
So to give you a feel ofactivity, last month in our
maternity unit we saw almost athousand women and the triage
(09:24):
team can see up to 50 women onour busiest day.
This is activity from a turn tounit that has around 5,000
births a year and therefore thisimplementation of a sensible
(09:45):
system for prioritising theorder in which women are seen is
very important.
Published data suggests thataround 15 to 20 percent of women
attending a maternity triagewill be amber, so we'll need
that required senior reviewwithin 15 minutes of arrival,
(10:10):
either because there's somethingwrong on their maternal
observations so, for example,raised blood pressure or rapid
pulse or respiratory rate orbecause of concerns about fetal
heart monitoring.
And if you look at the numbersof women that score red on the
(10:31):
triage system, the numbers aretiny, maybe two or three a month
.
So in this way it helps us notonly prioritize time wise the
women that really need rapidinput, but also the seniority of
(10:52):
doctor that they may see.
So we have excellent juniormembers of staff who are gp
trainees and they have excellentcore skills in recognising when
someone is unwell but theydon't have the specialist
knowledge and expertise ofmaternity care, certainly when
(11:21):
they start with us.
So they can safely see thewomen that are yellow or green
and have a longer timeframe inwhich to be seen and then
discuss with a senior colleague.
And we can hone our attentionin terms of more senior staff to
(11:45):
the red and amber women who mayneed that very timely
intervention to prevent them ortheir baby becoming very
seriously unwell very rapidly.
And it's much clearer now as aconsultant on call if someone
(12:06):
rings from triage or comesaround from triage and says they
have a woman scoring red oramber, I know I need to
immediately release someone togo and assess the situation and
see what needs to be done if Ican't go myself.
(12:36):
One of the key pieces ofpublished feedback from the
BSOTS implementation and BSOTSstudies are that staff found it
easier to communicate with oneanother about the urgency using
the colour coding system howquickly women needed to be seen
and what their concerns were.
So how does a woman turn up attriage?
(12:56):
So, coming back to our unitstats, around 78% of women
self-refer.
We also have extremely strictcriteria about which pregnant
women can and cannot be seen inthe main A&E department.
(13:22):
Pregnant women have differentsymptoms sometimes and different
physiological parameters whichare not necessarily well
understood by our emergencymedicine colleagues, and
therefore a small number ofwomen come to triage via A&E,
(13:45):
having been directed on asmaternity is a more appropriate
place for them to be seenbecause of the obstetric
expertise.
There has been a lot ofsuggestion of telephone
(14:06):
helplines and indeed in theRoyal College of Obstetricians
and Gynaecologists paper that Imentioned and I will put in the
show notes, there is also adviceabout dedicated 24-hour
telephone helpline, staffed by amidwife in a quiet place doing
nothing else, who can give herfull attention to women and give
(14:26):
advice on the phone, and thatis generally how we invite
people into the maternity unit.
We encourage them to phone thehelpline to discuss with a
midwife what the issue is andthen we can direct them as
appropriate as to whether theyneed to come in urgently to
triage or whether actually theycould wait for an appointment.
(14:49):
This makes it slightly easierfor us because we can give some
advice over the phone and we'vealso got some idea of who we're
expecting to walk through thedoor.
For example, sometimes if awoman rings up who thinks she
might be in pre-term labour, theteam will give us in the
(15:11):
neonatal unit the heads upbefore she's even entered the
building.
Some women will, of course,just appear, turn up of their
own accord.
Obviously, we have an open doorand we very much encourage
women to attend if they have anyworries.
(15:31):
Some women will be sent in bythe community midwives and some
women may possibly be sent in bytheir GP.
And that brings me to the otheraspect of triage.
Everything I've described up tonow might seem great, totally
(15:54):
standard, very good safety, andwhy wouldn't you want to do it?
But there is a flip side tothis whole triage issue in that
we're breaking up thatrelationship both with the
general practitioner, the GPs,and also potentially the
(16:18):
community midwives or midwiferyteams, because the first port of
call is starting to be thehospital, the hospital maternity
system and triage.
And there is some value in that, in that the hospital is open
24-7, it's always staffed.
(16:38):
There's always people there andif you've got a complication or
problem you don't want to besitting around waiting for an
appointment.
But it definitely breaks up thecontinuity.
Traditionally women, if theyhad more minor complications in
pregnancy, would contact theirmidwife or their midwifery team
(17:02):
and the midwife might phone themback, maybe arrange a visit or
fit them into clinic to have anappointment.
And because you've got thatcontinuity and they know that
woman and that woman knows thatmidwife, you then have the
ability to know what is a bitdifferent for that woman and how
that woman normally is, whather medical and obstetric
(17:26):
history is, and that might giveyou some pointers.
Whereas if a woman is phoning ahelpline or coming into triage,
chances are she's never met thestaff before.
They don't know her.
She doesn't know them.
And yes, we do now have digitalnotes and they can look on the
(17:48):
system and see what herappointments say and what the
history is and the interactionsshe's had with the maternity
service.
But it's not the same.
It's not relationship-basedcare, which has been very much
the basis of lots of maternitycare in the past.
(18:09):
Equally, gps certainly in mylocal area are completely now
excluded from maternity care.
It's very rare that when awoman has a difficulty in
pregnancy, she contacts her GP.
When a pregnant woman bookedher maternity care, one of the
(18:33):
first things that the midwifewould do at that first
assessment is decide what typeof care the woman was going to
receive, and one of the optionswas what was called shared care,
which was shared care with theGP.
So the woman would see themidwife for a number of
appointments and the GP for anumber of appointments.
However, this seems to havecompletely disappeared.
(18:58):
We don't have that shared carearrangement with our local GPs
anymore.
It's not their fault.
They're completely overloadedand my understanding is it's
also to do with the way the GPcontract works.
I believe that they don't havethose appointments included in
their contract anymore, but itcan mean that the GP is
(19:24):
completely out of theconversation of the care of that
woman for a period of time,which is not ideal if the GP is
someone who's very familiar withthat woman ideal if the GP is
someone who's very familiar withthat woman.
Gps may have lots of usefulinformation about the women on
(19:45):
their books, about their chronichealth conditions, if they have
them, and whilst that won'talways be important and of use,
I do feel that the emphasis onwomen self-referring to
maternity services and beingcared for by midwives and
(20:07):
obstetricians has really takenaway from that that the family
doctor had with that woman andwe're medicalising and bringing
everything into hospital.
So I was interested also when Iwas exploring this topic to
(20:31):
have a little look at what womenthink of the BSOTS system, and
there are a few small reportspublished, including one from a
hospital in Australia thatimplemented BSOTS.
That said women found itacceptable.
(20:52):
They had better communicationabout their likely waiting times
and they were more satisfiedwith that.
But I know from some women thatthey find it a very busy area.
They can be waiting for sometime.
(21:13):
They see a different team ofmidwives or doctors each time
they come and it isn'tnecessarily a great experience.
You might ask why we couldn'tuse the Manchester triage system
(21:34):
that's been in use since the90s in normal A&E and that's
because maternity has some veryspecific different parameters,
because your physiology changesin pregnancy.
So what we consider normalblood pressure, pulse and even
(21:56):
some blood tests are actuallyabnormal for pregnancy.
They're different.
We have different referenceranges for many things.
There are also importantsymptoms that in pregnancy may
be very significant that in thegeneral population might be
(22:21):
completely innocuous andtherefore you can't just apply
the same sort of triage systembecause you may not pick up the
women that are unwell.
This is why the triage systemhas to be maternity specific.
(22:50):
The other benefit for us inhaving implemented BSOTS is that
we can very clearly audit howwe're doing in terms of meeting
targets.
Are we seeing and assessingthose women in a timely way and,
if not, what were the barriersto that?
(23:11):
What were the blocks?
And there's a very clearescalation process in BSOTS.
If a woman is waiting longerthan she should be how you
escalate to the consultant oncall.
So, unlike previously, we'vegot a clear expectation of time
(23:31):
frames in which women might see,rather than an open-ended
situation.
And the CQC National Review ofMaternity Services published in
September 24 highlightedmaternity triage as a really
(23:52):
important first step for womenwith an emergency concern during
their pregnancy or theimmediate postnatal period the
first six weeks and was a safetyconcern in around a third of
CQC maternity inspectionsoverall, although they did
(24:23):
acknowledge that the RCOG paperand guidance had come out after
some of the inspections they'dhad.
So hopefully maternity triagewill be an area of rapid
improvement in the immediatefuture, do I think it's a good
system.
It definitely has some safetybenefits.
It can end up feeling a bitdisjointed and I think we need
(24:45):
to be careful about which womenare being seen in triage and
which women actually could waitfor an appointment with their
midwifery team or obstetric teamor GP.
I think some of theparticularly green women.
(25:07):
Do they really need to come tohospital?
Probably not, but there are somany things that worry women in
pregnancy.
You know you really want to bethere for those women that are
worried 24-7.
And that's definitely how weimprove safety for women and
(25:31):
babies.
But does it all need to come tothe hospital?
No, could we safely direct someof it elsewhere?
Maybe Could we do a better jobof women seeing their midwives
and GPs.
(25:51):
For some of the less urgentstuff, probably, but it's very
challenging because evensomething as simple as a urinary
tract infection, if leftuntreated, can make a woman
unwell, can risk the chance ofpreterm labour.
So it's very challenging not tosweep everything up into triage
(26:19):
and just try and make that assafe as one possibly can.
So what's my zesty bit, I think, for a woman, know that
maternity helplines and triageare there to be used.
You may have a bit of a wait ifsomething isn't urgent.
(26:43):
But if you're ever unsure abouta symptom or problem you're
having in pregnancy, it isalways better to ring your
maternity service and find out.
If you can easily get hold ofyour midwife and it doesn't seem
like an urgent thing to you,then great.
But at the end of the day, that24-hour number is your port of
(27:10):
call.
For anything you're worriedabout there's an expert who can
talk to about.
There's an expert who can talkto.
Never sit at home and worry.
We'd always rather you came andwe saw you and everything was
fine and you went away happy andreassured.
If you're a member of staff,then maybe you're very used to
(27:36):
this sort of triage, maybeyou're not, but bear in mind
that there's a reason why it'sbeen recommended.
There's good grounds for makingsure that women are seen in the
right order and those with moreurgency take priority and
(27:58):
however tempting it is whensomeone's been waiting a long
time or a longer time, to bumpthem forwards and and try and be
kind to them, actually it'sreally important that we stick
to that clinical prioritisationand only come to the women that
(28:20):
are non-urgent when all thoseare have been seen.
So it can be a bit frustratingwhen triage is busy and you've
got less, perhaps, doctorcapacity to review people.
But just keep like with anystructured tool, it's there for
(28:47):
a reason and if you stick tothat red, amber, yellow, green
you're not going to go wrong.
You're going to be safe on yourbusiest, busiest day.
Thanks for listening.
I very much hope you found thisepisode of the OBS pod
(29:07):
interesting.
If you have, it'd be fantasticif you could subscribe, rate and
review on whatever platform youfind your podcasts, as well as
recommending the OBS pod toanyone you think might find it
interesting.
There's also tons of episodesto explore in my back catalogue
(29:30):
from clinical topics, my careerand journey as an obstetrician
and life in the NHS moregenerally.
I'd like to assure women I carefor that I take confidentiality
very seriously and take greatcare not to use any patient
identifiable information unlessI have expressly asked the
(29:54):
permission of the personinvolved on that rare occasion
when it's been absolutelynecessary.
If you found this episodeinteresting and want to explore
the subject a little more deeply, don't forget to take a look at
the programme notes where I'veattached some links.
(30:15):
If you want to get in touch tosuggest topics for future
episodes.
You can find me at TheObsPod,on Twitter and Instagram, and
you can email me theobspod atgmailcom.
Finally, it's very important tome to keep the OpsPod free and
(30:39):
accessible to as many people aspossible, but it does cost me a
very small amount to keep itgoing and keep it live on the
internet.
So if you've enjoyed myepisodes and, by chance, you do
have a tiny bit to spare, youcan now contribute to keep the
podcast going and keep it freevia my link to buy me a coffee.
(31:05):
Don't feel under any obligation, but if you'd like to
contribute, you now can.
Thank you for listening.
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