The increased pace and involuntary nature of labour physiology renders it a period of maximum stress for both the fetus and the mother, particularly within the second stage of labour (McDonnell and Chandraharan, 2015). Women have described the value of compassionate supportive care during this time, which enables them to maintain a sense of control that is adjusted to their needs and wishes (Olza et al, 2018). The notion of control is consistently valued highly by women during childbirth, alongside an opportunity for active involvement in supportive, responsive care (Karlsdottir et al, 2018; Nieuwenhuijze and Low, 2013). The sense of feeling secure enough to be able to let go and become fully immersed within the process of labour has also been reported by women as an important factor, and facilitative of their sense of coping during labour (Anderson, 2010).
The provision of effective midwifery support during labour is paramount. Women who receive continuous labour support may be more likely to give birth spontaneously, be satisfied and have shorter labours; they are also less likely to require analgesia, have a caesarean birth or develop postpartum depression (Bohren et al, 2017). How we develop our interpersonal skills to provide personalised support to women may vary among midwives, and is influenced by their perceptions of the support systems available and their ability to exercise self-awareness, compassion and integrity during their relationships with women.
On a personal level, I can recall how during one-to-one consultations with women who had experienced traumatic births, mothers described their experiences of both supportive and unsupportive care during labour and the impact this had on their subsequent experiences of motherhood. From my own experiences of working in different clinical areas, I also understood how social expectations, the availability of resources and wider unit culture could influence my own practice. I reflected upon how such influences might subsequently impair or facilitate the provision of supportive care to women during birth.
This article considers the components that may contribute to the development of responsive intrapartum interpersonal skills and supportive personalised care during labour. Effective interpersonal skills are integral to midwifery practice (National Institute of Health and Care Excellence, 2014; Nursing Midwifery Council [NMC], 2017; 2018; World Health Organization, 2018), and highly valued by women (Nicolls and Webb, 2006; Bradfield et al, 2018). However, these are not always effectively applied within practice (Kirkup, 2015; Care Quality Commission, 2018). An increasing body of evidence demonstrates the value that the relational aspects of care has upon birth processes, of which interpersonal skills and communication play an important part.
Emotional intelligence is concerned with how we use our perceptions to manage the emotions of ourselves and others, whilst using this information to guide our thinking and actions (Salovey and Mayer, 1990; Goleman, 1998; 2004).
Emotional intelligence is described as a subset of social intelligence and associated with intuitive knowledge (Smith et al, 2004; Begley, 2006; Chaffey et al, 2012), and is positively correlated with competence (Heydari et al, 2016), as well as being a significant driver in the provision of safe, responsive and compassionate care to women. This is linked explicitly with effective leadership in the wider healthcare arena (NHS England, 2014; Carrager and Gormley, 2016; Heyhoe et al, 2016).
Understanding how midwives use emotional intelligence is particularly important, as the emotional workload of midwifery has gathered increasing attention during the last 15 years (Hunter 2004; 2005; 2006; Hunter and Deery, 2005; Hunter and Warren, 2014; Crowther et al, 2016). Midwives have reported experiencing considerable stress within the workplace, leading to wider recommendations around the concept of resilience as a mechanism to improve midwives' emotional wellbeing and subsequent interactions with women (Hunter and Warren, 2013; 2014).
The concepts of containment and reciprocity are incorporated as part of a particular skillset required for restorative clinical supervision (RCS), which forms the restorative arm of the A-EQUIP model introduced to replace statutory midwifery supervision in March, 2017(NHS England, 2017). Building upon the principles outlined within the Solihull theoretical model of parenting (Petit and Stephens, 2015), RCS aims to provide midwives with a safe space for reflection upon clinical practice with a skilled facilitator, and encompasses the theories of containment, reciprocity and behaviour management that were originally intended to improve a parent's emotional relationships with their child.
Containment refers to receiving and understanding the emotional communication of another without being overwhelmed by it and reciprocity, a sophisticated responsive interaction that improves relationship building. These concepts illustrate ways that midwives could respond to women during labour to facilitate the creation of a safe space for women to retreat into and feel safe enough to undertake the emotional and physiological work of labour.
Having the opportunity to be fully present with women appears to be conducive to midwives responding in ways that are reciprocal and attentive to women. This notion of presence has been identified as a key factor in the development of supportive responsive relationships with women within the wider midwifery literature (Sosa et al, 2012; Dahlberg and Aune, 2013). It is defined as a manifestation of midwives being with women within practice that is characterised by the support of the woman's emotional, physical, spiritual and psychological needs (Thorstensson et al, 2012; Davis and Homer 2016; Bradfield et al, 2018).
‘The provision of midwifery care…requires midwives to be able to negotiate several competing challenges simultaneously‘
Attentiveness is a key element of this (Dahlberg and Aune, 2013), and helps exemplify how the concept of ‘being present’ within midwifery-led care settings may differ from standard one-to-one care provided in labour ward settings. In these cases, midwives may demonstrate the phenomenon of absent presence, that is, remaining physically present in the room but without the provision of the emotional support characteristic of midwifery presence (Berg et al, 1996; Green and Harris, 2003; Hildingsson, 2015). This may be because of competing demands that are present within high-risk care settings and the introduction of technology.
Whilst technology within childbirth is necessary in certain situations, a consequence of this is that midwives may choose to adopt a task-orientated approach to care that is based on institutional factors and the wider culture within their unit, rather than provide care that is supportive and personalised to the individual woman. This is supported within the wider midwifery literature (Hunter, 2004; Davis-Floyd, 2018; Newnham et al, 2017) and may be reflective of a predominant focus on risk and its assessment, meaning that holistic care may not always be prioritised.
The provision of midwifery care during labour requires midwives to be able to negotiate several competing challenges simultaneously and provide care that is safe, supportive and woman centred. A dichotomy may present itself when midwives must demonstrate technical expertise aligned with the medical model of care, whilst continuing to provide personalised supportive care. Such challenges are particularly difficult in labour ward environments, where midwives may find it difficult to negotiate a terrain and find a path that balances between being emotionally present and available to women with technological advances and an increasingly complex population of women. The skills associated with RCS and a focus on developing our emotional intelligence within clinical practice may help to bridge this gap.