Comparative effectiveness of physical interventions for preventing perineal trauma during vaginal delivery: a systematic review and Bayesian network meta-analysis

Objective: Perineal trauma during vaginal delivery affects most primiparous women, causing significant maternal morbidity including chronic pain, sexual dysfunction, and impaired quality of life. While various physical interventions have been proposed for prevention, their comparative effectiveness remains unclear due to limited head-to-head trials. This Bayesian network meta-analysis systematically compared the efficacy and safety of all available physical interventions for preventing perineal trauma during vaginal delivery. Methods: We searched PubMed, Web of Science, Embase, and Cochrane CENTRAL for randomized controlled trials comparing physical interventions including massage, warm compresses, exercise, hands-on/off techniques, lubrication, education, or their combinations for perineal protection. Two independent reviewers screened studies, extracted data, and assessed methodological quality using the Cochrane Risk of Bias tool version 2.0. Bayesian network meta-analyses were performed using R Studio. Surface under the cumulative ranking curve (SUCRA) values were calculated to rank interventions. Results: Thirty-one randomized controlled trials involving 10,745 participants across 15 countries were included, of whom the majority were primiparous women with term singleton pregnancies enrolled in high-resource settings. For overall perineal laceration prevention, antenatal pelvic floor exercise ranked first (RR = 0.50, 95%CrI 0.28-0.87; SUCRA = 86.58%); for episiotomy prevention, massage combined with warm compresses ranked first (RR = 0.53, 95%CrI 0.28-0.93; SUCRA = 90.08%); for intact perineum promotion, massage demonstrated statistically significant superiority (RR = 1.93, 95%CrI 1.16-3.29); for severe perineal pain reduction, warm compresses had the highest SUCRA probability (SUCRA = 74.51%), though pain findings are exploratory given sparse network structures and wide credible intervals. All physical interventions demonstrated excellent neonatal safety. Education-only interventions showed no protective effects (RR = 1.03). Conclusion: Antenatal pelvic floor exercise represents the optimal first-line prevention strategy with 50% risk reduction. For women without prior training, warm compresses and intrapartum massage provide effective alternatives. Findings for pain outcomes should be interpreted as exploratory. Broader implementation of evidence-based physical interventions as evidence-informed strategies could help reduce the burden of perineal trauma, particularly among primiparous women in well-resourced settings, though generalizability to multiparous women and low-resource environments requires further investigation. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42025633266.