Non-verbal nurse-parturient communication in labor in Portuguese-speaking countries*

Objective: to analyze nonverbal communication between nurse and parturient during the active phase of labor in two Portuguese-speaking countries. Method: a quantitative and analytical study, whose sample consisted of 709 interactions that used the nonverbal communication of nurses and parturients. The analyzed variables were: distance; posture; axis; contact; emblematic gestures; illustrator gestures and regulatory gestures. For the analysis of the data, the Chi-Square and Likelihood Ratio tests were used. Results: the intimate distance between nurse and parturient in both countries (p = 0.005) prevailed. In both, touch was the most commonly used form of contact (p <0.0001). In both countries, the parturient remained lying down (p <0.0001). In relation to the established contact (p <0.0001), the parturient did not use contact. The face-to-face axis predominated in the interactions in both countries between nurse-parturient (p <0.0001) and parturient-nurse (p <0.0001). Conclusion: similarities were observed in non-verbal communication between nurses and parturients in both countries. However, there are differences such as the established contact between Brazilian and Cape Verdean nurses to parturients.


Introduction
The process of labor and birth, over the years, has ceased to be an individualized and physiological episode, becoming a process of interventions. In developed countries, childbirth is a process in which interventions are avoided and infrequent. However, there are still health professionals who make the parturition process a traumatic event, failing to establish an approximation with the parturient and ignoring the needs for privacy and comfort in the environment (1) .

The birth process in the hospital environment
gives new meanings to the birth process. Even with the existence of resources and technologies in these environments, the humanization model in the process of childbirth and birth presupposes that quality care is not synonymous with intervention and technology (2) .
In addition to the hospital, there are several environments where parturient care is provided, such as maternities, domicile, birth center and normal delivery center. The performance of deliveries at Normal Delivery Centers (NDC) is associated with lower rates of intervention during labor and delivery, however, gaps in care are still identified, providing women with physical, psychological and socio-cultural changes during labor and delivery that can affect maternal and newborn health (3) .
Professionals and women still find barriers to the implementation of more humane and quality obstetric care, such as the structural precariousness of the service, the lack of preparation of women for labor and delivery, and the lack of effective communication among health professionals and the parturient.
Through communication based on humanization, information, support, emotional support and affection are made available (4) .
In the sphere of nursing, the human being influences the world, is influenced by it and thus interacts with one another. In this sense, it is of fundamental importance, for Nursing care, the communication process, which can be understood as the set of verbal or non-verbal signs or forms transmitted and understood for the purpose of expressing ideas, feelings and thoughts (5) .
The human being communicates through verbal communication and non-verbal communication. Not always, non-verbal language is fully understood by professionals working in health services. This type of communication involves the body with its physical, physiological and gestural characteristics (5) .
Evidently, the nurse practitioner, who works in the care of labor, must understand non-verbal signals in order to reduce the patient's anxiety and transmit confidence and security. Non-verbal communication influences both the person receiving the message and the person sending it in different cultural and social settings.
For effective non-verbal communication at the time of labor, the absence of rude treatment, shouting, threats, humiliation and verbal aggression is indispensable (6) . However, this may be a reality experienced by many women in Brazil and other Lusophony countries. Thus, it is evident the need to analyze non-verbal communication in this obstetric reality in both lusophone scenarios. At this juncture, the study aimed to analyze the non-verbal communication between nurse and parturient during the active phase of labor in Brazil and in Cape Verde.

Method
This is a quantitative analytical study, performed in two scenarios (Brazil and Cape Verde): a Normal Birth Center located in a municipality in the metropolitan region of Fortaleza-CE (Brazil) and a maternity hospital located in Praia (Ilha de Santiago / Cape Verde). The data collection period was from March to August 2017 in both countries.
The study population, for both countries, consisted of generalist / obstetrician and parturient nurses. All participants were the senders and recipients observed in non-verbal communication during data collection. It is noteworthy that the analysis of verbal communication has already been described in another study. Parturient included women over 18 years of age, women in the active phase of labor and hemodynamically stable. For the nurses, the professionals who were on duty. Parturients with an indication of possible cesarean section or women at the end of the active phase were excluded. In Cape Verde, parturients who had difficulty understanding and speaking the Portuguese language were also excluded. There was no difference between the inclusion and exclusion criteria of the nurses between the countries, however, the lack of understanding of the Portuguese language was an exclusion criterion present only in Cape Verde for the parturients.
The sample consisted of the number of non-verbal interactions between nurse-parturient and parturientnurse during the active phase of labor, although the physiological process comprises three phases: Latent Phase, Active Phase and Expulsive Phase (7) . The After explaining the objectives of the study, the Informed Consent Form (FICT) and ethical aspects were met, the data collection instrument was started.
The instrument of data collection to evaluate non- The variable non-verbal communication defines the sender, being the nurse, parturient or absent.
In cases of lack of interaction, the instrument was marked as "absent". The distance was classified as intimate (zero to 50cm) and personal (50cm to 1.2m).
Regarding body posture, it was analyzed whether the participants, during the interactions, were standing, sitting, lying or kneeling. As for the axis that determines the position of the interlocutors in the communication, they were considered face-to-face, back-facing, sociofugitive (discouragement in interaction), partnerminded (encouragement in interaction) (5) .
The contact variable evaluated the physical contact within a short distance as the touch, caress/touch/ grasp, grasp, long hold, located touch, accidentally brush and no contact. The emblematic gestures were characterized as beating the foot and moving the hands, while the illustrated gestures recognize who complements the verbal language or not and the regulatory gestures contemplate the nodding of the head, the movement of the eyes and others (5) .
Each instrument was filled in every ten minutes.

All moments between the participants in this phase
were analyzed. At no time, the researcher influenced the interactions occurred, however, the free observation was used to enable a greater knowledge and approximation through the interaction between the researcher and the research context.
Data collection was performed with or without interaction between nurse and parturient. In turn, the interactions varied in each woman participating in the study. The interactions were analyzed during the whole period of the active phase of the delivery, being concluded with the end of the active phase or when the woman was referred for cesarean delivery.  Table 1     apparatus and internet in work places, it is noticed that the commitment of the professional nurse, in some moments of his / her assistance to the patient, has been helped or prejudiced along years (9) .

Results
The data from the study show that, in the two countries, the parturients established, in their interactions, nonverbal communication with the nurses (p = 0.018), presenting statistical difference.
Interacting with the professionals who assist you in the pre-delivery gives the woman greater freedom and confidence in the team.
The woman needs to feel welcomed to communicate with initiative and freedom with the nurses who assist her in labor. Effective non-verbal communication implies valid and positive results both in the physical and psychological aspects of this woman (10) . In this perspective, the literature affirms that women in labor need to give birth in a place where they exercise total autonomy to verbally express their feelings (11) .
In relation to distance, the intima was predominant bets on their participation in the improvement of this more humanized care (12) .
This approximation can be accomplished in the very exercise of care practices through simple interaction without requiring resources (13) . On the other hand, an "invasion" in the space of care can negatively affect the care process of women (14) . The absence of a spacious provides greater bonding and security to this woman in normal birth (15) .
The woman also expects, from the obstetrician nurse, a face-to-face look at humanization and care for this phase. Therefore, all the circumstances that involve birth and birth may leave marks, positive or negative, unforgettable in a woman's life (14) .
In the contact variable, there were also statistically significant differences between nurse-parturient (p <0.0001) and parturient-nurse (p <0.0001), in which the nurses in Brazil used no contact and touch, in Cape Verde, to establish interactions with parturients.
The touch was considered as a variable of non-verbal communication and could be used to express feelings to the recipient of the communication. In the context of obstetric care, where empathy and contact are paramount, it is necessary to use this resource for nonverbal communication (8) .
With regard to women in labor, no contact was   (16) . Parturients should express themselves through gestures and / or speeches in the labor process.
And free expression and autonomy is the right of every woman in the health services, and is indisputable in Brazil and in most other countries (17) .
Regarding the regulatory gestures, both in the It is essential the preparation of these women for the normal birth still in prenatal care that attends the pregnant women. It is necessary to provide guidance and attention to the needs of pregnant women, by assisting them in relation to normal birth and other orientations of this important event (14) .
In Brazil, women were instructed by nurses to walk. While walking, the parturients interacted more with their companion. The benefits of walking to facilitate labor during parturition have been widely reported in the literature (19) . Stimulating and assisting the woman to walk can provide a more affective and close communication between the professional and the parturient, thus minimizing negative feelings that may be experienced by these women.
Anxiety, nervousness, sadness and fear are still feelings expressed by women in parturition process in several countries of the world. In this reality, when a parturient has indication for normal delivery and is admitted to a maternity hospital, it is still possible to find some routine procedures, such as venous access, enema, absolute rest in the bed, inadequate vaginal touch, childbirth in the lithotomic position, Kristeller maneuver, among others (20) . These procedures further increase these feelings of insecurity presented above.
In a study carried out in Nigeria, it was noted the extreme need to create public policies to support and humanize African women in the process of childbirth and birth. The results of the research suggest that the implementation of well-designed policies would certainly increase the quality and satisfaction of women at the birth of their children (21) . In

Conclusion
According to the analysis, all variables studied presented data with statistical difference (p <0.05).

Intimate distance prevailed in interactions between
participants in the two countries. Similarities were observed in most of the analyzed variables of nurses and parturients in both countries.
However, there were differences in some, such as in the posture of participants.
As it was concluded, in this study we see the relevance of non-verbal communication in the care process in the obstetric scenario in both countries, with a view to providing humanized and quality care. In this sense, it is suggested to emphasize the importance of the communicative process for this assistance. It is necessary to prepare these women for the parturitive moment so that they interact, in the best way, with the health team and vice versa. It is proposed, for future studies, the development of strategies to promote the acquisition of knowledge about non-verbal communication for obstetrician and parturient nurses in both countries.