Objective To explore the influence of iliac vascular balloon preset on bleeding volume, complications and neonatal outcomes in cesarean section of pernicious placenta previa (PPP). Methods The clinical data of patients with PPP cesarean section admitted to department of obstetrics of the Affiliated Hospital of Xuzhou Medical University were retrospectively analyzed from January 1, 2021 to January 31, 2024. According to different hemostatic methods, they were divided into traditional group (traditional hemostasis) and balloon group (cesarean section after preset internal iliac artery balloon). The propensity score matching method (caliper=0.01, at a ratio of 1:1) was used to match the two groups, and 40 patients were included in each group. The surgical indicators, intraoperative and postoperative bleeding volumes, the number of blood transfusion cases and blood transfusion volume, neonatal outcomes (Apgar score, body weight) and postoperative complications (postpartum fever, hysterectomy, incision infection) were compared between the two groups. Results The surgical time and hospitalization time in balloon group were shorter than those in traditional group (P ＜ 0.05), and the postoperative body temperature was higher than that in traditional group (P ＜ 0.05). The intraoperative bleeding volume, bleeding volume at 12 h after delivery and bleeding volume at 24 h after delivery in balloon group were less than those in traditional group (P ＜ 0.05), and the blood transfusion rate and average blood transfusion volume were lower or less than those in traditional group (P ＜ 0.05). The neonatal Apgar scores at 1 min and 5 min after birth in balloon group were higher than those in traditional group (P ＜ 0.05), but there was no significant difference in neonatal birth weight between the two groups (P ＞ 0.05). The total incidence rate of complications in balloon group was lower than that in traditional group (2.50% vs 27.50%) (P ＜ 0.05). Conclusions The application of iliac vascular balloon preset in patients with PPP cesarean section can not only effectively reduce the intraoperative and postoperative bleeding volumes, but also improve the neonatal outcomes, with few postoperative complications.