Evidence & professional context
GRACE sits in a long line of nursing science and professional practice on perinatal staffing, acuity, and safety. The sources below are grouped by type: peer-reviewed articles first, then commentary, then AWHONN standards and historical guidelines, then convention posters. None of these studies or documents evaluate GRACE as software; they explain why shared workload visibility, guideline alignment, and disciplined surge response matter in Labor & Delivery.
Citations are for context only and do not imply endorsement of GRACE by authors, AWHONN, or publishers. Tier C items are professional standards and guideline products—not empirical proof of product outcomes. Tier D items are posters and proceedings, not peer-reviewed trials.
Tier A — Peer-reviewed research
Journal articles and analytic work on L&D staffing, acuity, technology, consequences of short staffing, and member input on standards. GRACE was not part of this research.
Hospital characteristics associated with nurse staffing during labor and birth: Inequities for the most vulnerable maternity patients
DOI: 10.1016/j.outlook.2023.101960
Simpson, K. R., Spetz, J., Gay, C. L., Fletcher, J., Landstrom, G. L., & Lyndon, A. (2023). Hospital characteristics associated with nurse staffing during labor and birth: Inequities for the most vulnerable maternity patients. Nursing Outlook, 71(3), Article 101960. https://doi.org/10.1016/j.outlook.2023.101960
Nurses' perceptions of critical issues requiring consideration in the development of guidelines for professional registered nurse staffing for perinatal units
DOI: 10.1111/j.1552-6909.2012.01383.x
Simpson, K. R., Lyndon, A., Wilson, J., & Ruhl, C. (2012). Nurses' perceptions of critical issues requiring consideration in the development of guidelines for professional registered nurse staffing for perinatal units. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41(4), 474–482. https://doi.org/10.1111/j.1552-6909.2012.01383.x
Predicting nurse staffing needs for a labor and birth unit in a large-volume perinatal service
Simpson, K. R. (2015). Predicting nurse staffing needs for a labor and birth unit in a large-volume perinatal service. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(3), 329–338. https://doi.org/10.1111/1552-6909.12549
Relationship between nurse staffing during labor and cesarean birth rates in U.S. hospitals
DOI: 10.1016/j.outlook.2024.102346
Lyndon, A., Simpson, K. R., Landstrom, G. L., Gay, C. L., Fletcher, J., & Spetz, J. (2025). Relationship between nurse staffing during labor and cesarean birth rates in U.S. hospitals. Nursing Outlook, 73, Article 102346. https://doi.org/10.1016/j.outlook.2024.102346
Identifying optimal labor and delivery nurse staffing: The case of cesarean births and nursing hours
DOI: 10.1016/j.outlook.2020.07.003
Wilson, B. L., & Butler, R. J. (2021). Identifying optimal labor and delivery nurse staffing: The case of cesarean births and nursing hours. Nursing Outlook, 69(1), 84–95. https://doi.org/10.1016/j.outlook.2020.07.003
Evidence-based perinatal nurse staffing
Bingham, D., & Ruhl, C. (2015). Evidence-based perinatal nurse staffing. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(3), 290–308. https://doi.org/10.1111/1552-6909.12544
The role of health care technology in support of perinatal nurse staffing
Ivory, C. H. (2015). The role of health care technology in support of perinatal nurse staffing. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(3), 309–316. https://doi.org/10.1111/1552-6909.12546
Consequences of inadequate staffing include missed care, potential failure to rescue, and job stress and dissatisfaction
DOI: 10.1016/j.jogn.2016.02.011
Simpson, K. R., Lyndon, A., & Ruhl, C. (2016). Consequences of inadequate staffing include missed care, potential failure to rescue, and job stress and dissatisfaction. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 45(4), 481–490. https://doi.org/10.1016/j.jogn.2016.02.011
Key findings from the AWHONN Perinatal Staffing Data Collaborative
Scheich, B., & Bingham, D. (2015). Key findings from the AWHONN Perinatal Staffing Data Collaborative. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(3), 317–328. https://doi.org/10.1111/1552-6909.12548
AWHONN members' recommendations on what to include in updated standards for professional registered nurse staffing for perinatal units
DOI: 10.1016/j.nwh.2021.08.001
Simpson, K. R., Roth, C. K., Hering, S. L., Landstrom, G. L., Lyndon, A., Tinsley, J. M., Zimmerman, J., & Hill, C. M. (2021). AWHONN members' recommendations on what to include in updated standards for professional registered nurse staffing for perinatal units. Nursing for Women's Health, 25(5), 329–337. https://doi.org/10.1016/j.nwh.2021.08.001
Tier B — Commentary & agenda-setting
Editorial commentary on gaps in labor-and-birth staffing research—useful for framing why better data and operations matter, not as empirical evidence for any product.
Research about nurse staffing during labor and birth is greatly needed and long overdue
DOI: 10.1016/j.nwh.2016.06.004
Simpson, K. R. (2016). Research about nurse staffing during labor and birth is greatly needed and long overdue. Nursing for Women's Health, 20(4), 343–345. https://doi.org/10.1016/j.nwh.2016.06.004
Tier C — Professional standards & guideline documents
Official AWHONN publications that define expectations for perinatal RN staffing. GRACE is designed to align operational workflows with such standards where hospitals adopt them—it does not replace them, collective bargaining, or employer policy.
Standards for professional registered nurse staffing for perinatal units
DOI: 10.1016/j.jogn.2022.02.003
Association of Women's Health, Obstetric and Neonatal Nurses. (2022). Standards for professional registered nurse staffing for perinatal units. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 51(4). https://doi.org/10.1016/j.jogn.2022.02.003
Guidelines for professional registered nurse staffing for perinatal units: Executive summary
DOI: 10.1111/j.1552-6909.2010.01147.x
Association of Women's Health, Obstetric and Neonatal Nurses. (2011). Guidelines for professional registered nurse staffing for perinatal units: Executive summary. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40(1), 29–30. https://doi.org/10.1111/j.1552-6909.2010.01147.x
AWHONN 2022 nurse-to-patient ratio reference
Source — AWHONN (2022) Standards ↗A condensed, paraphrased view of the nurse-to-patient ratios published in the AWHONN Standards for Professional Registered Nurse Staffing for Perinatal Units (2022). Use this as a quick in-app reference; rely on the source for full text, presumptions, and conditions that may modify any ratio.
- 1 : 2–3Nonstress testing
- 1 : 1Initial obstetric triage assessment
- 1 : 2–3OB triage post-initial assessment, stable
- 1 : 3Antepartum complications, stable
- 1 : 1Antepartum complications, unstable
- 1 : 1 (first hour)IV magnesium sulfate for preterm-labor prophylaxis — continuous bedside attendance for the first hour; on maintenance, no more than 1 additional couplet/woman per nurse
- 1 : 2Pharmacologic cervical ripening
- 1 : 1Labor with medical or obstetric complications (e.g., diabetes, pulmonary/cardiac disease, morbid obesity, preeclampsia, hypertensive crisis, multiple gestation, fetal demise, indeterminate or abnormal FHR patterns, TOLAC/VBAC attempt)
- 1 : 1Oxytocin during labor
- 1 : 1Labor with minimal/no pain relief or medical interventions
- 1 : 1Intermittent auscultation of fetal heart rate
- 1 : 1IV magnesium sulfate during labor — continuous bedside attendance through at least 2 hours postpartum; on maintenance, no more than 1 additional couplet/woman per nurse
- 1 : 1Initiation of regional anesthesia — continuous bedside attendance until stable (≥ first 30 minutes)
- 1 : 1Active pushing in second stage — continuous bedside attendance
- 1 : 2Labor without complications
- 2 : 1Birth — one nurse for the woman, one whose sole responsibility is the baby
- 1 : 1Immediate postoperative recovery (≥ first 2 hours) — continuous bedside attendance
- 1 : 3 coupletsMother–baby couplets after the 2-hour recovery window (mix acuity rather than all post-cesarean)
- 1 : 2Day-of-cesarean recoveries counted within a 1:3 couplet assignment
- 1 : 5Postpartum without complications (no more than 2–3 day-of-cesarean recoveries within a 1:5 assignment); newborns cared for by a separate nurse
- 1 : 3Postpartum with complications, stable
- 1 : 5Healthy newborns in a nursery whose mothers are not rooming in; mothers cared for by another nurse
- ≥ 1 nurse presentWhenever babies are physically in an occupied basic-care nursery
- 1 : 1Newborns undergoing circumcision or other surgery — pre-, intra-, and immediate post-operative
- 1 : 3–4Newborns requiring continuing care
- 1 : 2–3Newborns requiring intermediate care
- 1 : 1–2Newborns requiring intensive care
- 1 : 1Newborn requiring multi-system support
- ≥ 1 : 1Unstable newborn requiring complex critical care
- ≥ 1 nurse availableAt all times, with skills to care for newborns who may develop complications or need resuscitation
- Min. 2 RNsNeonatal specialty care for fewer than 6 intermediate-care or 4-or-fewer intensive-care babies
- Min. 2 RNs in hospitalEven when there are no perinatal patients — to safely manage an unscheduled obstetric emergency requiring cesarean (one circulator and one baby nurse, with neonatal resuscitation skills), with a scrub nurse / surgical tech available and another labor nurse on call for any new patient.
Summary only. AWHONN holds copyright on the full Standards document. These ratios assume ancillary support personnel are available; absence of such personnel may require more nurses. GRACE does not replace AWHONN standards, employer staffing policy, or clinical judgment.
Full reference: Association of Women's Health, Obstetric and Neonatal Nurses. (2022). Standards for professional registered nurse staffing for perinatal units. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 51(4). https://doi.org/10.1016/j.jogn.2022.02.003
Tier D — Convention posters & program reports
Non-peer-reviewed posters and proceedings examples (education, staffing tools, EHR acuity reporting). They illustrate implementation ideas and are cited at lower weight than Tier A.
An innovative longitudinal educational approach to maternal-child community health
No single DOI—link points to a relevant organizational or journal home for context.
Wright, M. (2015). An innovative longitudinal educational approach to maternal-child community health [Poster]. Proceedings of the 2015 AWHONN Convention.
Development of a staffing activity tool that works
No single DOI—link points to a relevant organizational or journal home for context.
Perinatal leadership team. (2017). Development of a staffing activity tool that works [Poster]. Presented at the AWHONN Annual Convention.
Using the electronic health record patient census and acuity data to determine acuity-based staffing in the labor and delivery unit
No single DOI—link points to a relevant organizational or journal home for context.
Jones, L., & Hall, V. (2021). Using the electronic health record patient census and acuity data to determine acuity-based staffing in the labor and delivery unit [Poster]. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 50(5, Suppl.), S13.