Perineal trauma at the time of vaginal delivery is common, and when the anal sphincter is included, these injuries can be associated with additional morbidity including incontinence, pelvic pain, and sexual dysfunction. The aim of this systematic review with meta-analysis was to evaluate whether a hands-on technique during vaginal delivery results in less incidence of perineal trauma than a hands-off technique. Electronic databases were searched from their inception until June 2018. No restrictions for language or geographic location were applied. The reference lists of identified articles were examined to identify studies not captured by electronic searches. Randomized controlled trials comparing a hands-on technique of perineal support during vaginal delivery (i.e. intervention group) with a hands-off technique (i.e. control group) were included in the meta-analysis. Hands-on was defined as involving one hand on the fetal head, applying pressure to control expulsion, with the other hand applying pressure on the maternal perineum. The primary outcome was severe perineal trauma, defined as either third- or fourth-degree lacerations. The meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of relative risk (RR) with 95% confidence interval (CI). Five trials, including 7287 women, were analyzed. All studies included singleton gestations with cephalic presentation at term undergoing spontaneous vaginal delivery. Women randomized to the hands-on technique had similar incidence of severe perineal trauma (1.5 versus 1.3%; RR 2.00, 95% CI 0.56-7.15). There was no significant between-group difference in the incidence of intact perineum, first-, second- and fourth-degree laceration. Hands-on technique was associated with increased risk of third-degree lacerations (2.6 versus 0.7%; RR 3.41, 95% CI 1.39-8.37) and of episiotomy (13.6 versus 9.8%, RR 1.59, 95% CI 1.14-2.22) compared to the hands-off technique. Hands-on technique during spontaneous vaginal delivery of singleton gestations results in similar incidence of several perineal traumas compared to a hands-off technique. The incidence of third-degree lacerations and of episiotomy increases with the hands-on technique. Key Message A hands-on technique during vaginal delivery results in similar incidence of severe lacerations compared to hands-off.