1. Howard, Elisabeth D. PhD, CNM, FACNM

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The experience of labor pain is multifaceted, making the assessment of a woman's response to labor complex.1,2 Labor pain is distinctly different from pain experiences associated with pathology, as it is connected to an inherently physiologic life-giving process.2,3 It involves both visceral and somatic pain and is influenced by emotions, culture, social support, prior experience, and environment. Because of the intricacies and uniqueness of this dynamic process, the assessment of labor pain is not a simple task. It is a challenge requiring sophisticated observation and clinical evaluation skills.1 The coping with labor algorithm was designed to capture the complexity of both the personal and observed experiences of labor pain whereas the traditional numeric rating scale falls short.1 In addition, this more holistic method of labor pain assessment meets The Joint Commission standards.4


Traditionally, methods of pain assessment in labor use numeric rating scales. According to the American Congress of Obstetricians and Gynecologists, pain relief in labor may be provided whenever medically indicated and maternal request alone is sufficient medical indication.5 Labor is complex and pharmacologic pain relief may decrease pain but may not relieve anxiety or suffering.4 Originally, the numeric rating scale was developed to address pain in a postoperative patient population.1 The use of a numeric rating scale does not adequately assess the multifactorial nature of the subjective experience of labor or the clinical assessment of coping with labor. Both women and nurses may be frustrated when a pain policy or assessment method is ineffective at addressing the needs of the population being cared for.6


To address the shortcomings of utilizing the numeric rating scale in this population, the coping with labor algorithm was developed at the University of Utah as a process improvement project initiated by a multidisciplinary team of midwives and nurses. The purpose of the project was to develop and implement a pain assessment, documentation, and management program unique to the laboring woman.1 In addition, women voiced dissatisfaction with being asked to "rate" their pain, and that the numeric rating scale was an intrusion into the goal of an unmedicated birth.1 A crucial aim of the project was to acknowledge and capture the complexity of the experience of labor pain, as it is affected by physical, environmental, personal, and cultural factors.2


The model employs 2 distinct paths: coping versus not coping. At the beginning of a shift and as needed, women are assessed for coping. Examples of coping and not coping were derived from extensive literature review as well as verbal reports from women. Some cues for coping include rhythmic breathing, relaxation between contractions, vocalization (moaning, counting, chanting), and rhythmic activity. Cues for "not coping" included writhing, tenseness, tremulous voice, lack of concentration, thrashing, clawing, and crying. The algorithm then continues on to suggested nursing interventions and coping resources.


Two divergent models of pain relief are acknowledged: the pharmacologic and nonpharmacologic models. A number of pharmacologic and nonpharmacologic techniques may be used to support women in coping with labor pain.4 The techniques branch into either pharmacologic or nonpharmacologic per a woman's stated desires or values regarding preferred pain management modality. For example, if a woman's goal is to have nonpharmacologic pain relief, suggested comfort measures such as hydrotherapy, massage, breathing techniques, hypnosis, and others are listed. The supporting level of evidence for each comfort measure is identified in the legend. The level of evidence ranges from "sufficient" to "no evidence and no harm." The pharmacologic branch of the algorithm includes the options of intravenous pain medicine, epidural, and nitrous oxide. Alterations that can be made in the physical environment to support coping include changes to lighting, music, temperature, and noise. The emotional support arm includes doula, midwifery, and one-to-one support care measures. The latest version of the Coping with Labor Algorithm (2017) is noted in Figure 1.

Figure 1 - Click to enlarge in new windowFigure 1. Innovative Pain Assessment.

Coping is a robust, well-defined concept in the psychology, nursing, and medical literature that has been around for some time. It was first defined by Lazarus and Folkman7 as a process of changing cognitive and behavioral efforts to manage a specific stressful situation. Coping strategies unfold in response to a stressor, such as a physical or emotional challenge. The coping process is elicited in response to an individual's appraisal of the situation, which includes fear of a loss of control.8 There are 2 main forms of coping: emotion-focused and problem-focused.9 Both forms of coping are typically used over the course of a stressful event and serve to palliate the emotions or distress produced by the situation. The usefulness of a coping strategy is evaluated in terms of whether or not it is appropriate for controlling emotional distress (eg, decreasing anxiety). In the coping with labor algorithm, the usefulness of a coping strategy is evaluated, and additional supports are suggested when necessary. Coping is a process that evolves over time for the individual. The perception or appraisal of the stress is affected by psychological preparation, expectations, past experience, and social support.


The coping with labor algorithm accounts for a woman's preferences and goals for the birth experience. Ideally, an assessment and documentation of a patient's core values and hopes for birth, preferred pain modalities and coping methods are elicited and documented prenatally. This dialogue with women involves ongoing communication before and during the process of labor.10 These values and priorities may be incorporated into the provision of appropriate coping resources during the process of labor and birth.


The coping with labor algorithm is incorporated into the Association of Women's Health Obstetric Neonatal Nurse Practitioner (AWHONN) Maternal-Fetal Triage Index.11 It is part of the American College of Nurse Midwives Healthy Birth Initiative, Reducing Primary Cesarean bundle, Promotion of Comfort and Care in Labor.3 In this bundle, this assessment tool and pain management approaches specific to labor pain are helping to better meet women's expectations and needs for comfort in labor.3 Shared decision making is an important component of the bundle.


The coping with labor algorithm more appropriately and completely captures the complex nature of the experience of labor pain. It is both woman-centered and driven by expertise of the nurse who is at the bedside, observing, supporting, and caring for the laboring woman. In addition, it is sensitive to a woman's values and preferences for nonpharmacologic versus pharmacologic pain modalities and represents a process of shared-decision making with the care team.


-Elisabeth D. Howard, PhD, CNM, FACNM




Nurse Midwifery, Women & Infants Hospital of Rhode Island


Associate Professor


Obstetrics and Gynecology (Clinical)


Alpert Medical School of Brown University


Providence, Rhode Island




1. Roberts L, Gulliver B, Fisher J, Cloyes K. The coping with labor algorithm: an alternate pain assessment tool for the laboring woman. J Midwifery Womens Health. 2010;55:107-116. [Context Link]


2. Lowe NK. The nature of labor pain. Am J Obstet Gynecol. 2002;186:S16-S24. [Context Link]


3. American College of Nurse Midwives. http:// Accessed January 31, 2017. [Context Link]


4. The American College of Obstetricians and Gynecologists. Approaches to Limit Intervention During Labor and Birth. Committee Opinion Number 687 February 2017. Obstet Gynecol. 2017;129:e20-8. [Context Link]


5. The American College of Obstetricians and Gynecologists. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 36, July 2013. [Context Link]


6. Gulliver BG, Fisher J, Roberts L. A new way to assess pain in laboring women: replacing the rating scale with a "coping" algorithm. Nurs Womens Health. 2008;12(5):404-408. doi: 10.1111/j.1751-486X.2008.00364.x. [Context Link]


7. Lazarus RS, Folkman S. Stress, Appraisal, and Coping. New York: Springer; 1984. [Context Link]


8. Folkman S, Moskowitz JT. Coping: Pitfalls and promise. Annu Rev Psychol. 2004;55:745-774. [Context Link]


9. Lazarus R. Fifty Years of the Research and Theory of R.S. Lazarus. New York: Lawrence Erlbaum Associates; 1998. [Context Link]


10. DeBaets AM. From birth plan to birth partnership: enhancing communication in childbirth. Am J Obstet Gynecol Call Action. 2017;216(1):31.e1-31.e4. DOI: 10.1016/j.ajog.2016.09.087. [Context Link]


11. Ruhl C, Scheich B, Onokpise B, Bingham D. Content validity testing of the Maternal Fetal Triage Index. J Obstet Gynecol Neonatal Nurs. 2015;44:701-709. [Context Link]