2 Effective Communication

Terri Rypkema, MEd, RCC

This chapter will discuss the effective interpersonal communication and counselling skills that play a large part midwifery practice: active listening, empathy, problem-solving and the core counselling skills of assessment, goal setting and using motivational tools.

From building a trusting relationship at the first appointment with clients through to the birth and the postpartum visits, midwifes will encounter many situations in which they will need effective communication tools in their repertoire and the skills to utilize them. Midwives will also use these tools with clients’ families, colleagues, other professionals, students, and others.

There will be times when the communication is urgent and factual and times when it will be warm and empathic as midwives need to relay everything from good to terrible news. Each time a midwife communicates, they must do so from the position of understanding who their audience is, what they want/need, what information needs to be conveyed, and what role their own thoughts and emotions play in the communication. It takes a great deal of self-awareness and practice to become an effective communicator.

6.1 Values & Self-Awareness in the Midwife-Client Relationship

To be an effective communicator and counsellor the midwife must understand their own values, beliefs and personal characteristics and how these may impact their work with clients. Our values provide guidance for us as individuals; determining what we believe to be right and wrong, and good and bad. They also influence what we deem to be of worth and importance in our lives. Whether we realize it or not, our values inform us in our everyday lives and in the client/counselling and client/midwife relationships.

It is essential that anyone working with people in any kind of counselling capacity be aware of their own values and beliefs, and be self-aware of their emotional, physical and mental response to the client. This means taking time to reflect on your beliefs and assess their effects on your feelings and emotions; that is, checking in with yourself to assess what is happening internally. You may ask yourself: Am I feeling strong emotions as I listen? Do I feel stress or discomfort in my body? Are there words and phrases running through my mind that prevent me from being able to fully attend to what the client is saying? As a midwife, if you are feeling emotionally activated, you can utilize self-regulation tools to manage the activation. Self-regulation tools include slowing down the breath, taking a sip of water, refocussing on the client and, if necessary, asking for a brief break in the meeting.

From this increased self-awareness comes the ability to set and maintain professional and personal boundaries. These boundaries provide emotional safety for both midwives and their clients as they navigate the transformative experience of birth together. Awareness of personal values and beliefs also allow the counsellors to work in a non-judgemental way with clients that have opposing values or refer such clients to an alternative resource more congruent with the client’s values. There is no standard that states that a counsellor must ignore their own values and beliefs entirely, but ethical practice requires that you not impose your personal values and beliefs on the person with whom you are counselling.

In most cases, it is not fair to expect midwives to ignore very strongly held values and beliefs in order to serve the needs of clients. There is no shame in acknowledging to oneself that it would be difficult, if not impossible, to work with certain clients because of a fundamental clash over values, beliefs, or consequently, behaviours. Referring the client to another midwife solves the problem while ensuring that the client receives the services they need.

6.2 Relationship Building

Along with self-awareness, relationship building will facilitate communication and possible counselling support as the midwife and client work together. This relationship is a professional one, with clear boundaries and expectations, but is still based on warmth and mutual acceptance.


What are the differences between personal/professional, physician/midwife, teacher/student relationships?

The essential elements of a helping relationship are listed below. The acronym PANG (positive regard, attending, non-judgement, genuineness) assists in remembering these elements:

6.2.1 Positive Regard

To develop and maintain a healthy clinical relationship, it is important that the midwife be able to maintain a positive manner in the company of the client. They need to portray a belief in the client’s strengths and abilities. The midwife also needs to be curious about the client’s values and beliefs around personal power, birth and family and to acknowledge and accept those beliefs and values as being fundamental to the client’s sense of self. (1) If the midwife has a strong sense of their own values and beliefs, it is more likely that they can view their client’s beliefs in a positive way.


What does positive regard look and feel like for the client? For the midwife? How do you know it is present?

6.2.2 Attending

When engaged in a clinical conversation, midwives have a number of tools at hand to demonstrate that they are engaged with what the client is communicating. Those practices include: orientating the body to the client’s face, sitting up in a relaxed and alert manner, making regular eye contact, using continuation sounds, such as “hmmm,” and “yes,” and nodding the head. These actions indicate interest and engagement in the conversation to the exclusion of all else. Keeping the hands and body fairly still and not toying with a pen or fidgeting in the chair will also communicate active listening. As a result of using these tools, the client should feel heard and know that they are the focus of the conversation for that period of time.


What are some of the mannerisms that you may have that could demonstrate inattention? e.g. doodling or fidgeting.

6.2.3 Non-judgement

It is essential that midwives demonstrate an attitude of non-judgement when meeting with clients. This is different from positive regard in that the client may be expressing disturbing material that might cause the midwife to be concerned or to feel ‘put off’ by the conversation. These feelings usually occur when the client is expressing values or beliefs that contradict those held by the midwife. During those times, the midwife needs to use self-awareness and emotional self-regulation skills to maintain positive regard for the client.

It is critical that the midwife be aware of values and beliefs that they cannot accept and to be ready to refer the client to another midwife or practice if a non-judgemental stance cannot be maintained. There is nothing wrong with acknowledging that a client’s values clash so absolutely with one’s own. Attempting to work in that environment is not helpful for either client or midwife.

6.2.4 Genuineness

Genuineness is a fundamental factor in any healthy relationship. It is especially important in a relationship where trust and ongoing communication are critical to ensuring a positive outcome – a healthy birth in the case of midwifery. The midwife can demonstrate genuineness through tone of voice, a warm manner, regular eye contact, and questions that indicate an interest in the client’s well-being.

6.3 Counselling Skills in Midwifery

While counselling is widely considered to be a treatment format for people with emotional or mental health concerns, most health providers find themselves offering some kind of counselling along with the services within their particular practice. Whether a physician is working with a patient to increase their motivation for losing weight, or a midwife is supporting a family through an adverse birth outcome, the tools they will use are no different from those used by a counsellor supporting a client through, for example, depression. It is, rather, a matter of degree of intervention.

Some of the situations in which a midwife will be called upon to enter into a counselling conversation may include: the client’s concerns about pain management, fear of delivery, a desire to change a habit to enhance their health and the health of the fetus, and so on. It is critical that the midwife have a clear understanding of when they can help the client and when the client should be referred to a mental health professional. Although not an exhaustive list, the following situations require a referral:

  • The client is not oriented to time or place or has significant cognitive deficits
  • The client is abusing drugs or alcohol
  • There is a report or a suspicion of domestic violence
  • The client is describing depression or anxiety that appears to be greater than the normal worrying or feeling “blue”
  • The client is demonstrating the symptoms of Post-Traumatic Stress Disorder (PTSD)

If the midwife is concerned that the client is presenting with symptoms that are confusing or very concerning, they should refer the client to a mental health professional for assessment. Most often, it is best to refer the client to their own family physician who can then make an appropriate referral.

In many cases, when there is no concern about the mental health of the client, the midwife may still want to refer the client and their family to community-based services, such as dietician, multicultural service agencies, or massage therapists.

6.4 What is Counselling?

The British Association for Counselling, now the British Association for Counselling and Psychotheraphy, may have been the first professional association to adopt a definition of professional counselling. In 1986 it published the following definition:

Counselling  is the skilled and principled use of relationship to facilitate self- knowledge, emotional acceptance and growth and the optimal development of personal resources. The overall aim is to provide an opportunity to work towards living more satisfyingly and resourcefully. Counselling relationships will vary according to need but may be concerned with developmental issues, addressing and resolving specific problems, making decisions, coping with crisis, developing personal insights and knowledge, working through feelings of inner conflict or improving relationships with others. The counsellor’s role is to facilitate the clients work in ways that respect the client’s values, personal resources and capacity for self-determination. (2)

This definition demonstrates how easily the practice of counselling fits into the practice of midwifery, but as you can see from the definition, there is little if no room for advising clients in the counselling setting. Of course, a midwife will advise the client on the medical aspects of the pregnancy, such as maintaining adequate nutrition or providing lactation support, but they may need to shift the focus to a guidance role when supporting the client to make certain decisions, change concerning behaviours, or to process an emotional concern.

Current models of counselling focus on what is called person-centred practice. Interventions are based on each client’s goals and draw from each client’s internal and external resources, whenever possible. Working from the client’s goals increases their sense of worth and accomplishment and reduces the chance of the client resisting change as they find it difficult to fight against something that they have identified as their desired outcome. Assisting a client to access their own resources allows that client to become more self-sufficient and more likely to generalize their self-knowledge and new skills to future problems.

6.5 The Righting Reflex: Avoiding Knowing What’s Best

Many people in the care-based professions believe that they know what the client needs. While this is necessary in acute situations, such as a medical emergency, in psycho-social settings, it prevents both the client and the counsellor from thinking outside the box when determining what is best for the client. In their haste to rescue the client from distress, those in care-based professions also risk ignoring the client’s needs altogether.

Motivational interviewing theorists call this the righting reflex. It comes from a place of caring and a desire to reduce suffering, but it often results in clients feeling misunderstood, over-ruled, and even invisible. It takes significant self-awareness and self-control along with a strong belief in the person-centred model of counselling to avoid getting caught up in the righting reflex.

Søren Kierkegaard captured the need to avoid the righting reflex beautifully in a piece of prose  he wrote in 1848.

If I want to successfully bring a person to a definite goal, I must find where he is, and start right there.
He, who cannot do that, fools himself when he thinks that he can help others.
To help somebody, I certainly must understand more than he does, but above all understand what he understands.
If I cannot do that, it is of no help that I am more able than he is and that I know more that he does.
If I still want to show how much I know, the reason is that I am vain and arrogant, and because I in fact want to be admired by the other rather than help him.
All true helpfulness begins with humbleness before the person I want to help, and thereby I must realize that to help is not a desire to rule but a wish to serve.
If I cannot do that, I cannot help anybody. (3)

The midwife must put their feelings and thoughts about what the client ought to do aside and listen carefully to what the client is saying about their thoughts, feelings, and needs. Reflective listening, empathy, and careful use of questions are all tools midwives may use to provide guidance and support for their clients. Often, the client will come into their own awareness of what they need to do to solve a problem just by talking it out with another person. This approach is the foundation of person-centred counselling.

6.6 Empathy as a Counselling Tool

Once a healthy helping relationship has been developed between the midwife and client, the counselling process can begin. The cornerstone of counselling is empathy. Merriam-Webster defines empathy as:

  1. the imaginative projection of a subjective state into an object so that the object appears to be infused with it

  2. the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner; also: the capacity for this

It is important to draw a distinction here between empathy and sympathy. Merriam-Webster defines sympathy as:

  1. a: an affinity, association, or relationship between persons or things wherein whatever affects one similarly affects the other
    b: mutual or parallel susceptibility or a condition brought about by it
    c : unity or harmony in action or effect <every part is in complete sympathy with the scheme as a whole — Edwin Benson>

  2. a: inclination to think or feel alike: emotional or intellectual accord <in sympathy with their goals>
    b: feeling of loyalty: tendency to favor or support <republican sympathies>

  3. a: the act or capacity of entering into or sharing the feelings or interests of another;
    b: the feeling or mental state brought about by such sensitivity <have sympathy for the poor>

  4. the correlation existing between bodies capable of communicating their vibrational energy to one another through some medium

Sympathy tends to remove the boundaries that belong in a professional relationship, allowing the participants to share the experience. However, a sympathetic response to a client is not likely to enable the client to move beyond the immediate feelings toward understanding because the midwife is colluding with client in the emotions the client is feeling. If the client is handing the midwife the tissue box instead of the other way around, it is likely that the midwife is sympathizing with the client and not empathizing. This is not helpful for the client.

An empathic response signals to the client that you understand their experience.  For example, saying something like “That must have been very hard for you” invites the client to explore those feelings further and expand upon his or her experience.


Why is empathy so important in the helping relationship?

Empathy is typically expressed in counselling sessions using a tool called reflective listening. In a reflective listening interaction, the counsellor/midwife engages the PANG skills, listens carefully to what the client is expressing and verbally reflects back their understanding of what the client is feeling. The client has the option of agreeing with the midwife or correcting them and restating what they are feeling. In either case, it is a successful interaction. If the midwife correctly identifies the feeling, the client feels heard and understood and will likely be open to further exploration of their concerns. If the midwife has misunderstood the client’s feelings, the client has the opportunity to correct them. This also enables the client to further clarify their thoughts and feelings.

An example of a reflective listening interaction:

Client I’m just not sure about having this baby at home. I’m worried that my other children will find it traumatizing.
Midwife You’re not sure if having a home birth is a good idea because your younger children may find the experience traumatic.
Client Yes, I’m worried that they will find the sights and sounds scary.
Midwife  You are worried that the labour and birth will scare the younger children.


While reflecting back the client’s feelings can make the client feel heard and understood, it often doesn’t encourage the client to explore their feelings more deeply or begin the process of problem-solving. There are additional tools the midwife can use to enhance reflective listening interactions and begin to move the client toward finding solutions.

6.7 Active Counselling Tools

6.7.1 Paraphrasing

In a counselling conversation, paraphrasing the client’s statements – not parroting back their feelings using their exact words – gives the client an opportunity to broaden their understanding of their situation. In hearing your interpretation of their feelings, the client has the opportunity to agree with or refute your reflection.

An example of paraphrasing:

Client I’m just not sure about having this baby at home. I’m worried that my other children will find it traumatizing.
Midwife You’re concerned about having a homebirth because it might frighten your children.
Client Yes, I’m worried that they will find the sights and sounds scary.
Midwife You are worried that the challenging process of labour and birth will frighten your younger children.
Client Yes, and they will be frightened by the strangers in the house, being awakened in the middle of the night, and the big change in their routine. I mean it is a bit scary for me, too, and I’m not sure that I can handle worrying about them as well as myself.
Midwife  You feel uncertain about your decision to have a home birth.

Notice that the client has now begun to talk about her concerns for the birth and not just her concerns about the younger siblings.

6.7.2 Summarizing

After a number of interactions that involve paraphrasing and reflecting back the clients’ statements, which helps them to clarify their concerns, the next step is to summarize the interactions.

An example of summarizing:

Client I’m just not sure about having this baby at home. I’m worried that my other children will find it traumatizing.
Midwife You’re concerned about having a homebirth because it might frighten your children.
Client Yes, I’m worried that they will find the sights and sounds scary.
Midwife You are worried that the challenging process of labour and birth will frighten your younger children.
Client Yes, and they will be frightened by the strangers in the house, being awakened in the middle of the night, and the big change in their routine. I mean it is a bit scary for me, too, and I’m not sure that I can handle worrying about them as well as myself.
Midwife So, it sounds like you wanted to have a home birth but you are now re-considering your decision because you have some concerns. You are a little worried about how the labour and birth may affect the younger children and you are concerned about whether or not you can manage their reactions while you are dealing with your labour.

6.7.3 Using effective questions

Questions are helpful in opening an interview, defining problems concretely, encouraging clients to elaborate on issues, establishing goals, and stimulating changes in thinking patterns. However, asking questions in a helping relationship can be a double-edged sword. On one hand, questions can elicit very important information such as occurs during an assessment. On the other hand, asking questions, especially too many questions in a counselling interaction, can cause a client to feel unheard, defensive, and distanced. A midwife must learn to use questions sparingly and thoughtfully as a way to assist the client to explore their emotional concerns.

It is critical that the midwife learn how to manage the timing, content, and purpose of questions in order to preserve the helping relationship with the client. Using questions in a counselling interaction is often where the righting reflex becomes apparent. In order to ask a question, the asker must have a hypothesis about what is happening for the client. The client’s answer will then either confirm or deny the hypothesis. If the hypothesis is grounded in what the midwife believes they know about the client’s needs, then the questions will naturally reflect that belief. This often leads to the client not being free to explore their own needs and, in some cases being manipulated into doing what the helper believes is best. While anyone working with a client must have some understanding of what the client is presenting and what they may need, the helper must keep an open mind and not ask targeted questions. Closed Questions and Open Questions

Closed questions and open questions are generally the most common types of questions. If a client is asked a closed question, they will likely go with the quickest answer, robbing themselves of the opportunity to contemplate what they truly think and feel about the topic. This automatic answering also decreases the client’s opportunity for self-awareness. Closed questions often end in awkward silence because the asker is usually hoping for more so that their hypothesis can be confirmed and the conversation can continue. It is important to remember that most clients won’t answer with just a ‘yes’ or ‘no’, especially once the helping relationship is formed. However, a carefully crafted open question will garner much more helpful information for the midwife and the client. You know that you have asked a good question when the client sits back and thinks for a while before answering – searching back in their memory or exploring previously unknown thoughts or feelings before answering. An excellent question will often trigger an ‘Aha!’ moment for the client and lead to a fruitful discussion about the issue. Note the difference between an open and a closed question:

Example of a closed question:

Midwife Did you use any pain management strategies with your first birth?
Client  No, I didn’t.

Turning a closed question into an open question:

Midwife What kinds of pain management strategies did you use for your first birth?
Client  I used some breathing exercises and my partner massaged my back, but it was still really awful. Clarifying Questions

There is a third type of question called a clarification question. A set of five open questions came out of the solution-focused therapy model (4) and have excellent applications in midwifery. These are questions that will help the client to explore their concerns, needs, internal and external resources, and wishes surrounding pregnancy and birth.


1) Exploration Questions

Clients will often report that they have been struggling with a problem for a long time before discussing it with a health care or mental health provider. It is important to use exploration questions to determine what kinds of strategies the client used to attempt to solve the problem. This will prevent you from suggesting something that has already been tried and from making the client feel judged for not being successful thus far. Sometimes the client has already discussed the problem with someone and it was not a good experience. It can be very helpful in the building of the therapeutic relationship to avoid making the same mistakes that an earlier professional made with the client.

An example of an exploration question:

Midwife How has your fear of morning sickness changed since it first began?
Client Before I got pregnant, I was terrified. I almost didn’t want to have children because of it. Now that I am pregnant, I’m still scared, but there is nothing I can do about it now, right?
Midwife How did this feeling change once you were pregnant?
Client Well, I guess my fear of being sick became less powerful than my excitement about being a mother.
Midwife  So, you are focusing on the positives of being a mother and not the worry of being sick.


2) Exception Finding Questions

Exception finding questions encourage the client to look at situations where the problem that they are having is not happening. The purpose is two-fold. The client is encouraged by the question to shift away from a ‘this problem is always present’ to a more reasonable, ‘this problem is sometimes not happening’ viewpoint. In addition, such questions invite the client to think about why the problem isn’t happening when it isn’t and to strategize ways to replicate the environment in which the problem doesn’t happen, thereby reducing the frequency of the problem. In the following interaction, note how the client is beginning to problem-solve on her own and has come up with two strategies she can use to stay confident and relaxed.

An example of exception-finding questions in midwifery:

Midwife When do you feel confident about your ability to breastfeed?
Client I feel pretty confident about it when my mother tells me how wonderful it was to breastfeed.
Midwife Why aren’t you worried then?
Client Well, I trust my mother. She doesn’t lie to me.
Midwife What is different between when you are worried and when you feel confident?
Client I feel more relaxed after I have talked with my mom and I believe that I will be successful because she has faith in me.
Midwife So how can you retain that relaxed and confident feeling when your mother is not with you?
Client  I could maybe write it down? Or remind myself when I start to worry?


3) Scaling Questions

Scaling questions are very useful for talking about the intensity of a physical or emotional feeling. Physical and emotional feelings are notoriously difficult to describe without having some way of setting common ground around the experience. The question can easily be customized to any situation using relevant language. The client presents a Likert scale verbally to the client, asking them to describe the intensity of their feeling on a scale of 1-5, or 1-10, assigning a value to each of the numbers.

An example of a scaling question:

Midwife On a scale of 0-10, with 0 being not anxious at all and 10 being so anxious that you cannot cope, how anxious are you about having a vaginal birth after cesarean for this baby?
Client  Oh, I would say that I am at a 7 or 8. I’m pretty worried about it.

Scaling questions are also useful for having discussions about what would need to happen to change the rating up or down and to explore progress the client has made.

An example, continuing from the conversation above:

Midwife So, you are at a 7or 8 today. What could happen that would reduce the anxiety to 4 or 5?
Client  Well, you could tell me more about how a vaginal birth after a cesarean works.


4) Coping Questions

Coping questions help the client to become more aware of their inner resources. Often, clients will have coped with a problem for some time before seeking help. However, they frequently don’t recognize what skills they have been using to manage. Once the midwife points out that they have these internal skills, the client often becomes more confident in their ability to cope.

An example of a coping question:

Midwife How did you manage to stay calm during the miscarriage scare early in your pregnancy?
Client Well, I made sure that I stayed off my feet during those two weeks and I phoned my Mom every day and I asked my sisters to come and make meals and watch my son after school each day.
Midwife  So it sounds like you were very resourceful in terms of asking for help, staying rested, and getting lots of emotional support from your Mom.


5) Relationship Questions

Relationship questions assist the client to look at their own future behaviour without judgement, helping them to set goals. The midwife can ask the client what someone else would notice about them if they made a change in their behaviour.

An example of a relationship question:

Midwife What would your partner notice about you if you decided that you would no longer listen to the horror stories of birth that your friends insist on telling?
Client  Well, I guess my partner would see that I have stopped worrying and that I was sleeping better and not having bad dreams.

Clearly, questions are a very important part of care provision. Questions, in conjunction with active listening practices enable the midwife and client to move into the process of finding or creating solutions to stated concerns or for the midwife to make appropriate referrals for more specialized care.

6.8 Assessment

Assessment is an integral part of the health and counselling professions. It is essential to understanding the client’s emotional and physical strengths and needs. The science of assessment can mean asking a lot of questions, which can impede the development of the counselling relationship, but that does not have to be the case. If the midwife is skillful in the art of assessment, which involves using the counselling skills outlined above – relationship building, using effective questions, listening and reflecting, the client will feel the midwife is ‘with’ them. Assessment takes time but is the foundation of a trusting and effective communicative client/midwife relationship.

6.9 Talking to Clients about Change

Change is difficult for most people and becoming a parent is one of the most challenging changes that a person can make. Many of the changes that occur in the process of becoming a parent are outside the client’s control, but many clients also desire to make behavioural changes, such as quitting smoking, eating better, exercising more, or repairing familial relationships. Despite the desire to make these changes, it is often difficult for clients to begin the process and/or follow through.

An effective tool for midwives to talk to clients about change is the transtheoretical model of behaviour change (5) developed by James O. Prochaska and Carlo DiClemente. This model describes the five stages through which a client will pass on their way to making a significant change in their life.

External Link

More information about the transtheoretical model of behaviour change can be found at the University of Maryland, Baltimore County website: http://www.umbc.edu/psyc/habits/content/the_model/index.html

6.9.1 Precontemplative Stage

During this first, precontemplative stage, the client is unaware that they need to make a change although other people around them may be concerned about their behaviour. Until the client becomes aware of any need for change, the midwife can only provide what is called passive information. Ideally, the midwifery clinic/office will have passive information available to clients in the waiting area. Many professionals make use of this passive way of providing clients with information on a variety of issues and concerns that may come up during pregnancy through the use of posters, brochures, websites, and seminars.


6.9.2 Contemplative Stage

Once the client has become aware that they want to make a change in their behaviour, they are deemed to have reached the contemplative stage. In this stage, the client has realized that a certain behaviour of theirs has become detrimental in some way or wishes to enhance or add a positive behaviour to increase the likelihood of a healthy pregnancy and birth. During this stage, the midwife becomes an active provider of information, such as referrals to a specialist and/or media with specific information about the concerns. The midwife may share their own expertise depending on the behaviour change the client is wanting to make. It is during this stage that the midwife will make the most use of counselling skills. Asking open questions and helping the client to explore her feelings about making the change naturally leads to the next stage.


6.9.3 Planning Stage

In this stage, the midwife can assist the client to anticipate any obstacles to successfully making a change and generate a plan to eliminate or reduce those obstacles. This is often a very active and practical conversation. For example, the client may anticipate that they are unable to attend a smoking cessation program because they do not speak English well. The midwife may have information about such programs being offered by multicultural agencies in the community.


6.9.4 Active Stage

Generally, the client is doing the hard work of making change in this stage and the midwife takes the role of monitor and, occasionally, coach. Often, the client is accessing a service outside of the midwifery practice, such as smoking cessation, nutrition counselling, or parenting classes, and the midwife’s role is just to check in with how the client is doing during normal prenatal check-ups.

6.9.5 Maintenance Stage

In this stage the client learns ways to maintain the changes that they made and, most importantly, to develop a relapse prevention plan. This plan is a critical part of the maintenance stage. The client develops a plan, anticipating the possible ways in which the desired change could be derailed and outlining how derailment threats will be managed if they occur. Most relapses in behaviour change are the result of not planning for times when it becomes very difficult to maintain the change, such as attending a party where others are smoking, or holidays that include many sugary treats. A good plan for handling these threats makes it much more likely that the client will be able to maintain the desired change.

Despite the client’s best efforts, relapse is a very common and normal aspect of making change. It is important for the midwife to reassure the client that change is difficult, that going back to an old and unwanted behaviour doesn’t mean starting at the beginning again, and that there is something to be learned from the relapse. Most relapses occur because either something was missed during the planning stage or during the relapse prevention part of the maintenance stage. Either way, the client should be encouraged to look at the early successes in making change and to look at what went wrong so that they can use that information to try again while avoiding the pitfall they encountered the first time.

Sometimes, clients wanting to make a change in their emotional or physical lives have trouble developing and/or maintaining the motivation to make a change. The midwife can play an important role in this situation by using motivational interviewing (6) techniques to assist the client to achieve her goals.

Motivational interviewing strategies are designed to assist the client to look at the difference between what they want (e.g. to be a non-smoker) and what they are now (a smoker). Rather than attempting to convince the client that they should stop smoking the midwife can ask questions that encourage the client to look at why they want to make the change.

An example of a motivational interviewing interaction:

Midwife In what ways do you think your body will feel different once you have stopped smoking?
Client I don’t know for sure, but I guess I won’t feel as breathless and I won’t feel sick all the time.
Midwife It sounds like smoking is making you feel unwell right now and you can see that you will feel better when you stop smoking.
Client Maybe, but I’m not sure.
Midwife How did you feel when you smoked your first cigarette of the day today?
Client Oh! I felt so lightheaded and nauseous. And I worried about what it was doing to the baby.
Midwife I hear you are concerned for both yourself and the baby when you smoke.
Client Yes, I am concerned. It wasn’t important to me before, but now I have the baby to consider as well. I really shouldn’t be doing something that could harm the baby.
Midwife  It sounds like you want to do what is best for you and the baby.

Note that the midwife is not judging the client for her behaviour but is, instead, helping the client to explore her own experience of smoking and the impact it has on her and her baby. This exploration most often leads to development of internal motivation in the client to make a positive change.

6.10 Difficult Relationships & Difficult Conversations

There will be times when, despite the midwife’s and the client’s best efforts at communication, the relationship and/or conversation will be strained. Perhaps the client has trouble building trust or the midwife is being influenced by feelings that arise if the client reminds them of someone they had a negative experience with in the past. Perhaps their communication styles are so opposite that they just can’t connect. There will be times when the midwife must relay difficult information, challenge the client, or manage a difficult conflict with a client’s family member or another professional.

The first step in dealing with difficult conversations is to ensure that you feel physically and emotionally grounded. Most people go into what is called the ‘fight or flight’ mode when involved in an intense interaction with another person. This makes it very difficult to think and respond clearly and thoughtfully during the conversation.

The fight or flight mode is a basic human instinct that is managed by a small structure in the brain called the amygdala. When the amygdala senses some kind of threat, it sends out a chemical signal to the sympathetic nervous system to prepare the body to respond to the threat. New research has found that a normal healthy human will do one of five things:

  1. Friend (i.e. seek help.)
  2. Fight
  3. Flee
  4. Freeze
  5. Flop (When there have been multiple threats with no resolution and the person fails to respond.)

These five responses are thought to be the brain’s way of ensuring survival. Of course, a difficult conversation is not a threat to one’s survival as such. However, the amygdala does not discriminate very well between types of threat. It will respond to the emotional threat of a challenging verbal interaction in the same way, albeit with less intensity, as it would to a physical threat.

Once the chemical message is sent out in response to threat the body responds automatically through the sympathetic system. Heart rate and blood pressure will increase, breathing becomes more quick and shallow, and the digestive system will shut down. These changes allow the body to divert needed resources – blood and oxygen – to the arms and legs in order to facilitate the fight, flight, or freeze mode. The person experiences these physical changes in feelings of light-headedness, heaviness in the arms and legs, pounding heartbeat, heavy feeling in the stomach, feeling flushed and hot, and generally agitated.

The chemical messaging and organization of this process is managed primarily by the hormone cortisol. Besides managing all the changes in the brain and the body, cortisol also shuts down the hippocampus. When a person has been threatened, the brain doesn’t ‘want’ the person to take time to think about what to do to resolve the threat because in the time it takes to think about it, the threat could become fatal. This shutting down of the hippocampus results in people feeling disoriented and incapable of thinking clearly. After a threat, people report that they ‘just couldn’t think straight’, ‘felt like they were in a fog’, ‘couldn’t concentrate or cope’. (7) It is this feature of the response to threat that makes communication in an emotionally risky situation so difficult.

There is a way to prevent or stop this cascade of physiological events from happening. In order to turn off the threat response, one must turn on the parasympathetic system. The ‘on switch’ for the parasympathetic system is deep and slow breathing. Humans have a natural way of doing this that most of us take for granted. If you think back to a time when you saw something that was frightening you may remember that after the threat was gone, you probably took a big deep breath and said blew it out saying “Whew!” when it was over. People witnessing a near collision often turn to each other, take a deep breath and exclaim, “Wow, did you see that?’ while exhaling. (8) This is the body’s way of turning on the parasympathetic system to reset the heart rate and breathing rate to normal values.


Think back to a time when you were very frightened. (Do not try to think of a time that may trigger a very strong emotional response, such as a traumatic event). Try to remember the first moments after the event.

How did you express your immediate thoughts and feelings?

Do you remember laughing or crying?

How did you interact with the people who may have witnessed the event with you?

Can you think of other times that you felt similar physiological sensations? When angry? Frustrated? Pressured? Rushed?

The midwife can use breath to prepare for a difficult conversation by spending a few minutes privately preparing by taking two deep breaths and letting them out slowly and then breathing on a count of one-two-three-four on the inhale and one-two-three-four on the exhale. This exercise will call in the parasympathetic system, calm the heart, lungs and brain, and bring the hippocampus back ‘online’. (9)

During a difficult or challenging conversation, the midwife can manage their breathing, taking a deeper breath when noticing the heartrate increasing and concentrating on keeping the breaths deep and even. This is a useful tool that midwives can teach to their clients to use to assist them with managing stress, pain, and emotional distress.

In addition to managing the physiological impacts of difficult conversations, the midwife can use a number of strategies and tools to ensure that the conversation is productive. An important tool is ensuring you understand exactly what it is you want to convey. If there is time, think about the goal of the communication. Write down some of the points that need to be made. Make sure that you have any facts that may be relevant at hand. If you are expecting a very difficult conversation, try to rehearse it in your mind. While breathing in a steady manner, visualize the conversation. Imagine yourself being calm and grounded, saying what you need to say and listening to the other person. Often, discomfort and fear about difficult conversations is caused by not knowing what might happen. Having rehearsed the conversation once or twice, the brain will not recognize the real conversation as being novel and will likely keep the body more relaxed and open. (10)

An important tool to use in challenging conversations is to use ‘I’ messages as opposed to starting sentences off with “You…”.  For example, “You are wrong”.  The midwife can begin a conversation with “I am concerned about …” This approach reduces the possibility that the listener will feel defensive and allows them to hear the words being spoken. There is a higher chance of the listener wanting to engage further in the conversation if they are not fighting against the speaker.

An example:

Midwife I am concerned about the birth plan not being followed as the client had written it. It states that they did not wish to have medications offered, but would ask for them if they felt they were needed.

When providing or receiving feedback, the brain will likely have a similar threat reaction. As with other difficult conversations, it will be important to maintain the breath and keep the hippocampus working well. When the hippocampus is working well, it is possible to hear the feedback, compare it to other similar feedback situations and not be overwhelmed by one’s emotions. Good feedback should always include some positive information, some realistic and reasonable information about what went wrong and how it could be done better. Feedback should never be about personal characteristics. It should address specific behaviours that the receiver can change.

6.11 Relaying Bad News

There are very specific tools to use when relaying difficult information such as the death of an infant. It is important to remember that many people experience what is called a flashbulb memory of the time they received terrible news. It is critical that the midwife be mindful of the language used, the tone of voice, body language, and location for the conversation.

When relaying bad news, it is best to choose a location that is as private as possible, where there are chairs to sit on and is big enough to include family and friends if the circumstances warrant. Ideally, there will be tissues, soft lighting, and the room will be in a quiet place. The midwife should use a calm and soothing voice to relay the information. It is important to state the information clearly and simply while giving plenty of time and emotional space for strong reactions. Initially, there may be expressions of disbelief, rage, blame, tears, or complete silence. There is no hard-and-fast rule about how people will react to emotionally difficult news. The midwife must stay calm, soothing, and be prepared to answer questions when the client is ready. In most situations, the midwife will just sit and be a witness to the family’s grief in the early moments of the meeting until the information is absorbed and initial feelings expressed. After that, there will likely be many questions. It is important to answer questions clearly and simply, as with giving the news initially. If the midwife does not have enough information, they can tell the client that they will get the information as soon as they can and will contact them later. At this time, it is very helpful if the midwife can provide the client and family with information about community supports and any medical information that might be helpful, particularly in dealing with perinatal loss, such as advice and support for the mother on how to manage lactation.

6.12 Engaging Partners in the Birth Process

It is important for the midwife to look to the client for direction about who they wish to engage in their pregnancy journey and birth. Typically, the client and intimate partner, family member, or close friend will attend the initial consultation with the midwife. At this time, it is most helpful to discuss what each person’s role will be in the process.

The midwife may be asked by the client for advice on who to include in prenatal visits and who could or should attend the birth. This is an excellent opportunity for the midwife to use reflective listening skills and questions to help the client raise awareness about what their needs might be throughout the pregnancy and birth.

An example conversation:

Client I’m not sure who I want to be there for the birth. Of course I want my partner to be there. My sisters both had our mother there, but I don’t know if that is what I want.  
Midwife It sounds like you are sure that you want your partner there for support but you are feeling ambivalent about having your mother there. Let’s look at the pros and cons of having her there in the room with you.
Client Well, if she is in the room with me, I won’t be worrying about her hanging around the hospital popping in every few minutes to ask what’s going on and she’s pretty good at giving back rubs.
Midwife So she can provide some physical comfort. I’m also hearing that you are concerned that she will be distracting if she isn’t allowed to be there and I’m wondering if you are worried that she could be just as distracting in the room with you.
Client Yes, I’m worried that I’m going to be distracted by her worrying and I won’t be able to concentrate on what I have to do. She tends to take up a lot of emotional space. I want a peaceful and calm birth, if I can.
Midwife Sometimes, parents can hover in a distracting way because they want to be able to help but they don’t know what to do. I’m curious about how your sisters handled your mother during their births.
Client  Well, one asked her to bring her homemade broth to sip on during labour and asked Mom for her famous back rubs. The other is the easy-going one and just let Mom do her thing. The thing is, I am more private and introverted than my sisters and I just realised that I don’t have to do everything the same way they do. What I really want is for my partner and I to have a quiet and private birth experience. I could ask Mom to be the communications person and my partner can keep her updated by phone. That way, she has a job and feels included and I get the birth that I want.

Occasionally a family member or friend will attempt to engage the midwife in conversation about the client either by phone or email or at some time during the pregnancy and/or birth without her knowledge. One way to deal with this is to invite the client to provide a list of people with whom the midwife can share information. If someone not on the list attempts to communicate, the midwife is obliged to remind the person that all information about the client is confidential and that the midwife cannot speak about the client without written permission. At that point, the midwife may contact the client to say that they received a request for information and ask for direction.

6.13 Further Skill Development

In addition to effective communication skills, counselling skills, and self-awareness, the midwife needs to have specific knowledge of aspects of pregnancy, birth, and family dynamics that can impact the client’s life. Important topics to explore are: typical and non-typical family development, pregnancy loss, grief and trauma, mental health and substance abuse, and the resources available for specialized counselling and mental health services. The many psycho-social aspects of birth, including inclusion of birth partners in decision-making, working with other professionals in the birth process, supporting marginalized families also need to be considered. The student midwife is encouraged to take workshops and classes on these topics in order to enhance helping skills with midwifery clients.


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Effective Communication Copyright © 2017 by Terri Rypkema, MEd, RCC is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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