A retrospective cohort study analyzed 223 high-risk pregnant women who delivered vaginally between January 2023 and December 2024; the patients were included in the group of traditional delivery lying on the back (TSD, n = 117) or in the group of delivery in the free position combined with perineal massage (FPPM, n = 106). In the FPPM group, the active first stage of labor was shorter (5.98 ± 1.25 h vs. 6.28 ± 1.41 h; p < 0.05) and the second stage of labor was shorter (85.48 ± 7.85 min vs. 94.?? min; p < 0.05) [data on the second value in the text incomplete]. The FPPM group had a lower rate of perineal lacerations (59.43% vs. 76.07%; p = 0.008) and fewer episiotomies (16.04% vs. 27.35%; p = 0.05). After delivery, the proportion of women with bleeding ≥ 500 ml was higher in the TSD group (62% vs. 13.68%; p = 0.045). FPPM also reduced the need for intrapartum anesthesia and the number of postpartum complications; The 5-minute Apgar score of newborns was higher in the FPPM group (9.80 ± 0.35 vs. 9.69 ± 0.42; p = 0.036). Maternal satisfaction was higher in the FPPM group (69.81% very satisfied vs. 52.14%; p = 0.028). The authors conclude that free position birth with perineal massage in high-risk women was associated with better nursing quality indicators, lower incidence of perineal trauma and postpartum complications, better neonatal outcomes, and higher maternal satisfaction.