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Abstract Background Prenatal education improves maternal and neonatal outcomes. Ultrasound-guided visual biofeedback provides real-time visualization of fetal head movement, enabling expectant mothers to refine their pushing techniques. Pelvic floor muscle training may improve the ability to contract and relax the pelvic floor during labor. When used during the second stage of labor, US-BF has been shown to confer obstetrical benefits. Implementing prelabor ultrasound-guided visual biofeedback can further improve motor learning and optimize pushing effectiveness during the second stage of labor. This study aimed to evaluate the feasibility and effectiveness of pelvic floor physiotherapist-led prelabor ultrasound-guided visual biofeedback for improving obstetrical outcomes. Methods A single-blinded randomized controlled trial was conducted in a community clinic. The study was approved by the Ariel University Human Ethics Committee (20211128) and registered on ClinicalTrials.gov (ID: NCT05258786). Nulliparous women at term with singleton pregnancies in vertex presentation were randomized into three groups: (1) Intervention: Prelabor transperineal and transabdominal ultrasound-guided visual biofeedback for pelvic floor muscle training and second-stage pushing training, (2) Control: Verbal instructions for pelvic floor muscle training and second-stage pushing, and (3) Routine Care: Standard prenatal education. In-person training sessions were held at an outpatient physiotherapy clinic between 37 and 39 weeks of gestation. Within the intervention group, pushing efficacy was assessed using the angle of progression, and pelvic floor muscle contraction efficacy was assessed using bladder base displacement across the pre-, during-, and post-biofeedback phases. Obstetric outcomes, including second-stage duration, mode of delivery, perineal integrity, and postpartum urinary retention, were retrieved from medical records. Stress urinary incontinence was assessed using the International Consultation on Incontinence Questionnaire–Short Form before delivery and at two and eight weeks postpartum. Results Out of 161 randomized women, 120 completed the study. In the intervention group, pushing efficacy showed a significant quadratic pattern, improving during biofeedback and declining after visual feedback was withdrawn (p = 0.007), while pelvic floor muscle contraction efficacy remained largely unchanged. Compared to the combined control and routine care groups, the intervention group had significantly lower rates of operative vaginal delivery (p = 0.050), higher rates of an intact perineum (p = 0.025), and lower rates of postpartum urinary retention requiring catheterization (p = 0.039). No significant differences were found in second-stage duration, cesarean delivery rates, or stress urinary incontinence outcomes. Conclusions Physiotherapist-led prelabor ultrasound-guided visual biofeedback for second-stage pushing and pelvic floor muscle training was feasible and associated with improved obstetrical outcomes. These findings suggest a promising direction for enhancing prelabor education and maternal preparation. The study was approved by the ethical review board (Ariel University Human Ethics Committee Noa Ben Ami − 20211128, Ariel University, Israel) and registered on ClinicalTrials.gov on February 18, 2022 (ID: NCT05258786). Prior to enrolment, informed consent was obtained from all participants. All procedures were conducted in accordance with the ethical standards of the institutional research committee, and the 1964 Declaration of Helsinki and its subsequent amendments.
