Objective
To reconsider the use of episiotomy by critically appraising research papers with a high evidence level.
Method
We applied EBN methodology used to clarify clinical issues and searched for research papers and guidelines with a high evidence level. The keywords perineotomy/episiotomy, perineal laceration, perineal pain, and newborn were used. We focused on, and critically appraised, 2 research papers that are systematic reviews of RCT, and at the same time, we examined midwifery knowledge concerning minimizing perineal tears.
Findings
Our critical appraisal found that in both systematic reviews research queries were clearly defined and all points needed to insure validity were present. These systematic reviews advised that, "Compared to restrictive episiotomy, implementing routine episiotomy increases the risk of 'posterior perineal trauma'. It also increases the risk of 'healing complications' and 'perineal pain' at the time of hospital discharge. There is no evidence of reduction in the risk of 'urinary incontinence', 'dyspareunia', or the incidence of 'problems with newborn health'."
In addition, our examination of current midwifery knowledge confirms the possibility of minimizing perineal tears through perineal massage, perineal protection, and innovative birthing positions.
Conclusion
In women-centered midwifery care, the midwife seeks possible treatments that minimize perineal tears, and at the same time, shares evidence-based information appropriately with the aim of building a partnership with women so that women can choose care treatments themselves.

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Purpose
The purpose of this research is to search for the care needs of mothers who have lost children due to stillbirth and their thoughts and experiences on this, and find a direction this care should take.
Method
The research design was a qualitative factor search type research. There were a total of 14 participants, including 13 mothers who had experienced a stillbirth after the middle term of the pregnancy and one mother who had experienced early neonatal death within the first hour of birth. Data were collected by semi-structured interviews using an interview guide. The results were analyzed using continual comparative analysis. In order to ensure the validity of the analysis, the participants confirmed the results.
Results
The results of the analysis indicated three core categories. The first related to "support me becoming a mother" -reaffirm the bonds that have been formed between mother and child during pregnancy, and support her self-realization that she is a mother. Second, "support for working through the grief process" -when the grief process brought on from experiencing loss begins, help guide her through the proper grief process. Third, "work out my wishes and support my decision-making" -respect the mother's decisions on various levels related to care and develop mother-initiated care.
Within "support me becoming a mother", I extracted the following four categories: "support all my wishes in seeing and parting with my child", "I want mementos that are proof that my baby lived", "provide support through cremation and burial services", and "my baby should be treated as if he were alive". For "support for working through the grief process" I extracted the following five categories: "help me talk out and listen to my stories of my child and my experiences", "assurance that it's O.K. to cry and provide an environment where I can cry", "an environment that won't add to my pain", "after-hospital support and information", and "support for the family to support the mother". Finally, "work out my wishes and support my decision-making" was a total, comprehensive care need.
Conclusion
Mothers who have experienced a stillbirth have care needs based on supporting them becoming a mother, supporting them in working through the grief process, and working out their wishes and supporting their decision making.

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Purpose
This study was undertaken to investigate the emotional responses of mothers to the crying of their 1-to-12-month old infants.
Methods
Survey 1: During a public well-baby checkup for one-month olds, a survey using a self-entry questionnaire was given to 763 mothers, for the purpose of analyzing the emotional responses of mothers to their crying infants. The questionnaire contained 20 questions to gain information about accepting and non-accepting reactions of mothers when they hear the cries of their infants.
Survey 2: When the infants reached age 4-5 months, a similar self-entry questionnaire survey was given to 429 mothers who had consented to participate in this longitudinal study during Survey 1.
Survey 3: When the infants reached age 12 months, a similar self-entry questionnaire survey was given to 305 mothers who had consented to participate in this longitudinal study during Survey 2.
Results
An analysis was made of the responses of the mothers who had participated in all three surveys made during the first 12 months after the births of their infants. Of these mothers, 124 (49.0%) were primiparous (49.0%) and 127 (51.0%) were multiparous.
At 1 month after birth, the accepting emotional scores of the mothers averaged 30.6±5.3 (range: 10-40) and their non-accepting emotional scores averaged 18.0±6.3 (range: 10-40). At 4-5 months after birth, the accepting scores averaged 29.8±5.9 and the non-accepting scores averaged 17.6±5.8. At 12 months, the scores were 28.2±5.8 and 18.9±6.1, respectively. Thus, accepting emotional score tended to be high throughout the first 12 months after birth, reaching a peak at 1 month after birth and decreasing significantly over time (p<0.05-0.0001). The non-accepting emotional score was higher at 12 months than at the other points of time after birth (p<0.05-0.0001). At 1 month, the accepting emotional score was higher among multiparas than among primiparas (p<0.05), while the non-accepting emotional score was significantly higher among primiparas than among multiparas (p<0.01). These differences in emotional score depending on previous experiences of parenting were specific to one month after birth and were not carried through to the later periods.
Conclusion
In a longitudinal survey of 251 mothers, acceptance of crying was high among mothers of one-month-olds, but it decreased gradually over time. At 12 months after birth, non-acceptance predominated over acceptance (a reversal of the earlier relationship between acceptance and non-acceptance).

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Purpose
The purpose of this study is to explain women's value system which was consisted of three stages (Customary standard and Maintainable want, Hopeful standard and Adaptable want, Unific standard and Agreeable want) about having amniocentesis.
Method
1) Sample: They were sixteen women who had a choice to do amniocentesis and had heard the results without any chromosome abnormality and in normal pregnancy.
2) Design: The design was qualitative, retrospective description with semi-structured interviews and had gathered information from chart with their consent.
Results
Except one whose brother-in-law had Down's syndrome ,they were over 35 years old. There were twelve women who had decided to do amniocentesis in a low stage of their value system; Usual standard and Maintainable want. The contents of Usual standard were their mental weakness and physical limits to think about having a handicapped baby. Maintainable want was to keep stable present life like now. The difference between wife and husband's Usual standard and Maintainable want had caused trouble in women without Hopeful standard and Adaptable want, because they could not get husband's agreement. On the other hand, there are Unific standard and Agreeable want which women had wish to know about reasons doing amniocentesis like them or not. And they had expected to justify their choice and to feel at ease.
Conclusion
Women's value system about having amniocentesis were three stages of Standards and Wants. They were Customary standard and Maintainable want, Hopeful standard and Adaptable want, Unific standard and Agreeable want.
Many women as samples in this research had priority over Usual standard and Maintainable want; a low stage of their value system. It means their choice to do amniocentesis were not with well thoughts.

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Purpose
The purpose of this study is to identify actual situations and problems at childbirth in clinical settings, when midwives provide care for people from culturally and linguistically different backgrounds who have settled in Japan, considering cultural issues in childbirth.
Method
In this descriptive study, data were collected using semi-structured interviews, following initial interviews, both of which were conducted by the researcher. The subjects of the study were sixteen midwives who were working at maternity wards in hospitals in Tokyo, and who had experience of caring for people from diverse cultures. Context analysis was conducted to develop a coding system, and the data was then revised into meaningful categories.
Result
Midwives recognized that they often didn't understand the feelings of people from diverse cultures, and often felt uncomfortable when interacting with them. They found relationships with people from diverse cultures to be stressful, but believed that having the same language is not important in communication. They also had the attitude that it is important to get to know people from diverse cultures in order to develop a positive relationship. As[m1] for childbirth culture, the midwives felt confusion in relation to different attitudes towards childbirth, and a difficulty in providing care that was in accordance with cultural practices, as this would sometimes deviate from the hospital rules. However, the midwives wished to provide culturally appropriate care at childbirth for people from diverse cultures, just as much as they would wish this for Japanese people. They aimed to do this by collaborating with other healthcare practitioners.
Conclusion
It was noted that midwives recognize difficulties in communication and differences in childbirth culture, and that they make an effort to provide care that respects cultural practices so that the mothers have wonderful childbirth experiences. However, the establishment of systems in which there is collaboration with other healthcare practitioners is essential to improving care for people from diverse cultures.

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Purpose
This study attempted to clarify how effectively breast massages change subjective indisposition of gloom, engorgement, and mammary surface skin temperature by utilizing the Oketani style breast massage during the child weaning period.
Method
Subjects were 10 women who received the Oketani style breast massage from 1 year to 2 years and a month after birth. A midwife measured engorgement, and the mothers measured subjective indisposition of the mammae before and just after the massage using the visual analog scale. Mammary surface skin temperature was measured with the Thermo Tracer (TH5100, NEC) device. Data were gathered before the first breast massage and then just after, at intervals of 1, 3, and 5 minutes. The maximum and mean mammary surface skin temperature were measured by the Thermal image treatment program (TH51-701).
Result
The subjects clearly complained of gloominess, but their gloom was improved after massage on the 3rd and 10th weaning days. The engorgement of mammae was reduced by the mammary massage. The mammary surface skin temperature of 7 out of 8 subjects rose after the massage on the 3rd weaning day. The mammary surface skin temperature of 2 out of 6 subjects rose, and the other 4 subjects' temperatures fell after the massage on the 10th weaning day.
Conclusion
Over all, the use of the Oketani style breast massage in the child weaning period proved to be more effective for improving blood circulation of the whole mammae and is an effective way to reduce a mother's mammary discomforts.

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Purpose
The aim of the study was to identify the specific difficulties and dilemmas faced by nurses caring for infertility patients.
Methods
A qualitative descriptive study was carried out on 12 nurses working at institutions employing Assisted Reproductive Technology (ART). Using a semi-structured interview, the subjects were asked to give their comments on the difficulties faced when caring for infertility patients and their thoughts on such occasions. Transcripts of the interviews were analyzed and similar results grouped based on specific difficulties.
Results
Difficulties experienced can be broadly divided into three categories. The first difficulty cited by nurses interviewed was inability to provide care taking into account the particular characteristics of infertility patients. Subjects indicated that they had difficulty forming relationships with patients that had built a wall around themselves and with answering patient concerns. The second difficulty encountered by subjects was their inability to approach patients when treatment results had turned out contrary to patient expectations. Nurses became involved in what patients were experiencing, feeling sad and helpless, and showed a tendency to avoid patients at such times. The final problem faced was nurses' unwillingness to become involved in patient choices regarding treatment options. Nurses stated that they did not want to become involved in helping patients to make their own decisions or provide advice not in line with the physician's treatment policy.
Conclusion
The difficulties and dilemmas faced by nurses were attributed to their stereotypical view of patients and the inadequacy of the supporting relationship between patients and nurses. The study revealed that it is important for nurses to take greater interest in patients and accept them as they are in order to build patient-nurse relationships in which both parties can express their thoughts and wishes freely and openly.

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Purpose
The present study was conducted in order to extract factors contributing to women's feelings for the 18 months following an Emergency Cesarean Section, and to identify more clearly the process involved in the progression of change in feelings.
Method
In-depth interviews, guided by semi-structured questions, were conducted with five primiparas, who had experienced an Emergency Cesarean Section 13-19 months before their interview. Interview data was tape-recorded, and analyzed qualitatively.
Results
The following 7 factors were extracted from the data: 1. panic as a result of the emergency situation; 2. feelings of dissatisfaction and trust regarding medical staff both during and after the birth; 3. self-condemnation for having an Emergency Cesarean Section; 4. discomfort as a mother; 5. a change of feelings toward the Emergency Cesarean Section; 6. ease evoked by the support and comfort from their husband and the people around them; and 7. changes in attitude towards childcare with gradual adaptation from feelings of pain to feelings of joy.
Conclusion
The present results indicate that the feelings of women who experienced an Emergency Cesarean Section are greatly influenced by the women's views towards birth. In addition, women's feelings are influenced by the reaction of the husband to the Emergency Cesarean Section. Regarding nursing, the present results indicate that women feel increased relief and increased understanding consequent to repeated explanations. Furthermore, to determine whether psychological support is necessary, nurses should review and listen to women in order to ascertain their thoughts about childbirth. Finally, the study suggests that we must consider the influence of the shock and reaction of the husband to the Emergency Cesarean Section upon the woman's feelings.

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Purpose
The purpose of this study is to understand the decision making process of pregnant women who have to consider whether to undergo amniocentesis or not.
Methods
The subjects, who all gave their consent to be interviewed, were 5 women in their 26th to 30th week of pregnancy. The women were interviewed in a semi-structured manner and interviews were recorded and transcribed. A qualitative method was used for an in-depth analysis of the interviews. Units of meaningful descriptions were classified into various main categories. The categories were determined by making small changes after each interview.
Results
Three of the 5 women refused to undergo amniocentesis and 2 agreed to it. As regards the process of decision making about whether to go through with the birth or have an abortion, four key categories to be pondered by the pregnant women were identified. These are as follows: 1) ask yourself whether to go ahead with the birth or not, 2) confirm your own sense of value about abortion, 3) judge your own opinion by comparing with that of others, 4) envisage what rearing a disabled infant would be like.
The starting point of the process is that pregnant women ask yourself whether to go ahead with the birth or not. The process is not one-way to the determination. While the women are wavering mentally about whether or not to continue the pregnancy, they consider the ramifications of these four categories.
Conclusion
The results suggest that this process of mental reflection and wavering over a period of time before the final decision is made is extremely important as it alleviates the pregnant woman's emotional conflict.
The pregnant women feel wavering when they have the clash of their sense of values and their emotion. And an important matter is affirms the pregnant woman's emotional conflict and their sense of values.

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Purpose
The purpose of this study was to examine the relation of anxiety and feeling for the baby to the background of infertility treatments in pregnant women.
Method
The subjects in this study were 250 pregnant women of outpatients in the three clinics at urban area. They were requested to fill up self-report questionnaires. The main contents of these questionnaires were the characteristics, the prenatal anxiety scale, feeling for the baby scale. The awareness of from infertility treatment start to pregnancy by Visual Analog Scale was requested to the women who had infertility treatments.
Results
201 questionnaires gave replies (response rate was 80.4%). The women who had infertility treatments were 53 and those who had no infertility treatments were 148. In the expectation for the baby and the changes to the mother's physical appearance of the prenatal anxiety, the women who had no treatments were more anxious than those who had treatments significantly. The women who had treatments were better condition than those who had no treatments on feeling for the baby. The women in a latter pregnancy period were higher prenatal anxiety than those in an early and middle period. The high prenatal anxiety women were not good status feeling for the baby. As the result of comparing the women who had the new technology of fertilization (e.g. in vitro fertilization) with those who had the general infertility treatments, the former feel less distress for treatments and treatments costs than the latter. Therefore, it is necessary to give a counseling and education for the high anxiety women.
Conclusion
It is important to give support to pregnant women whether or not infertility treatments.

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