Objective: To study real‑world decision‑making experiences, decision‑making bases and influencing factors of clinical midwives in perineal protection during vaginal delivery, analyze decision‑making dilemmas regarding perineal protection, episiotomy and prevention‑and‑control of perineal injury, and provide empirical evidence for standardizing midwifery perineal management, reducing the incidence of maternal perineal injury and improving clinical midwifery decision‑making. Methods: Adopting a qualitative phenomenological research method, maximum‑variation sampling was used to recruit 12 clinical midwives from a municipal maternal‑child specialized hospital and a maternal‑child health‑care hospital as research subjects. Semi‑structured in‑depth interviews were conducted from February to August 2025. The Colaizzi seven‑step analysis method was applied to sort, code and extract interview themes. Results: Major considerations for perineal‑protection decision‑making, restrictive factors in perineal‑protection implementation, critical decision‑making indicators for episiotomy, as well as occupational stress and cognitive bias in the decision‑making process were identified. Midwives’ decisions mainly relied on four core indicators: perineal elasticity, fetal weight, labor progress and maternal cooperation level. Their decisions were also affected by clinical experience, working environment, doctor‑patient perceptions, institutional norms and other factors. Junior midwives tended to make conservative decisions and perform excessive episiotomy, whereas senior midwives were prone to empirically‑biased decision‑making. Conclusion: Midwives’ decision‑making for perineal protection represents a process combining objective medical indications and subjective empirical judgment. At present, clinical practice is characterized by inconsistent decision‑making criteria, heavy reliance on experience and prevalent risk‑avoidance‑oriented decisions. Hospitals shall establish standardized decision‑making workflows, strengthen tiered training, improve midwifery practice environments, enhance the scientific nature and standardization of perineal‑protection decision‑making, and lower the rates of perineal injury and unnecessary episiotomy.