The National Institute for Health and Care Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on Insertion of a balloon device to disimpact an engaged fetal head prior to emergency caesarean section, in March 2015.


Obstructed labour poses considerable risks to a mother and her baby, often leading to the need for an emergency caesarean section. This can be difficult if the fetal head is fixed (engaged) deep within the mother's pelvis.

Two approaches are commonly used to disimpact an engaged fetal head. One involves the surgeon or midwife placing a hand through the vagina and pushing the baby’s head back up the pelvis. This is often associated with vaginal tissue trauma. The other approach (reverse breech extraction) involves the surgeon delivering the baby’s feet through the uterine incision, and then delivering the head. This method is associated with fetal hip injury, shoulder injury and facial or neck trauma, and is avoided whenever possible. Difficulties in disimpacting an engaged fetal head often delay the delivery of an already compromised fetus. There is a risk of the complications described above and also risks of obstetric haemorrhage, injury to uterine vessels and trauma to the urinary tract.

Coding recommendations

The OPCS-4 code for insertion of a balloon device to disimpact an engaged fetal head prior to emergency caesarean section are:

R27.8 Other specified other operations to facilitate delivery

The Clinical Classifications Service has advised NICE that currently these are the most suitable OPCS-4 codes to describe this procedure. The OPCS-4 classification is designed to categorise procedures for analysis ant it is not always possible to identify a procedure uniquely.

Your responsibility

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. 

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

  • National Institute for Health and Care Excellence (NICE)