This article describes the association among perineal outcomes, selected risk factors, and alternative intrapartum approaches used by nurse-midwives. This nonrandomized concurrent (cohort) study analyzed all spontaneous vaginal births (N = 1211) attended by nurse-midwives at a university hospital over a 2-year period. Univariate analysis was used to calculate relative risks for the associations between two perineal outcomes and selected variables. Study results indicated that parity, ethnicity, birth weight, and use of two techniques (hot compresses and lubrication) were associated with lacerations. The same factors that increase the risk of perineal lacerations also made the performance of an episiotomy more likely; however, for episiotomy, an inverse relationship with perineal hot compresses was noted, and perineal lubrication had no effect. Lack of perineal support was associated with a 66% rise in the risk of episiotomy. Use of birthing positions other than lithotomy significantly reduced the likelihood of episiotomy. The authors concluded that selected care measures to protect the perineum may reduce maternal morbidity and simplify intrapartum care. The risks and benefits of alternative strategies commonly used by nurse-midwives while caring for diverse populations during birth should be further evaluated in large multiethnic populations.