Managing Obstetric Emergencies: ER & EMS Basics

Learning Goal: This curriculum is designed to equip emergency department clinicians, pre-hospital providers (EMS), and first responders with the vital knowledge and physical skills necessary to triage, assess, and stabilize pregnant patients, manage critical delivery complications, and perform immediate neonatal resuscitation in non-obstetric settings.

• Prerequisites: Basic Life Support (BLS) or Advanced Cardiovascular Life Support (ACLS) certification is recommended.
• Estimated Study Time: 12 Hours

Module 1: Pregnancy Anatomy and Physiology Basics

This module establishes the core foundation of maternal-fetal anatomy and the profound physiological changes that occur during a normal pregnancy. Understanding these baseline shifts is crucial for identifying when a pregnant patient's vital signs or physical presentations deviate into pathology.

Recommended Videos

Reproductive System, Part 4 - Pregnancy & Development: Crash Course Anatomy & Physiology #43

@crashcourse03:212,028,485

Reproductive System, Part 4 - Pregnancy & Development: Crash Course Anatomy & Physiology #43

Pregnancy triggers profound anatomical and physiological changes in the mother's body. The uterus expands dramatically from fist-sized to filling the entire abdominal cavity, displacing organs. The placenta secretes multiple hormones including relaxin (loosening joints), human placental lactogen (promoting fetal growth and preparing breasts for lactation), and continues estrogen and progesterone production. Blood volume increases by up to 40%, forcing the heart to work harder and potentially cau

@crashcourse · 03:21

• Why this video: This video offers a highly visual, fast-paced overview of how the uterus expands to fill the abdominal cavity, displacing maternal organs. It clearly explains the development of the placenta and umbilical cord, setting a strong anatomical baseline for non-obstetric clinicians.
• Knowledge Checkpoint:
  • Understand how the uterus expands from its non-pregnant state to fill the entire abdominal cavity, altering landmark anatomy.
  • Explain the basic function of the placenta as a selective barrier and temporary organ of exchange.
  • Identify the structural relationship between the maternal uterine wall, the placenta, and the umbilical cord.

Physiological Changes during Pregnancy

@Learningin1007:4092,007

Physiological Changes during Pregnancy

Pregnancy induces profound physiological changes across multiple body systems: cardiovascular changes include a 50% increase in cardiac output due to elevated stroke volume and heart rate (15 bpm higher), with decreased systemic vascular resistance; respiratory changes involve a 150% increase in minute ventilation driven by progesterone, decreased functional residual capacity (20%), and increased oxygen consumption (40-50%) causing chronic respiratory alkalosis; hematological changes manifest as

@Learningin10 · 07:40

• Why this video: This lecture highlights key physiological adaptations in pregnancy, particularly the cardiovascular shifts. For ER and EMS providers, recognizing that a 50% increase in cardiac output and a 15 bpm heart rate increase are normal is essential for accurate vital sign assessment.
• Knowledge Checkpoint:
  • Recall normal cardiovascular adaptations, including blood volume expansion and baseline heart rate elevation.
  • Explain how respiratory and renal parameters shift to meet maternal-fetal metabolic demands.
  • Define the baseline hematological changes, such as physiological anemia of pregnancy.

Chalo PYQS karein -in obs and gynae for neet pg with DR Sakshi Arora Hans.

@DrSakshiAroraHansobsandgynae12:37326,715

Chalo PYQS karein -in obs and gynae for neet pg with DR Sakshi Arora Hans.

This section covers comprehensive physiological adaptations during pregnancy. Hematological changes: blood volume increases more than RBC volume, causing decreased hematocrit and hemoglobin concentration. RBC lifespan shortens, increasing erythropoietin and reticulocyte count. WBC increases, platelet count decreases (benign gestational thrombocytopenia) but never below normal. All clotting factors increase except Factor 11 and 13. Cardiovascular changes: cardiac output, stroke volume, and heart

@DrSakshiAroraHansobsandgynae · 12:37

• Why this video: This detailed academic breakdown reviews advanced maternal physiological adaptations. It explains why hematocrit and hemoglobin concentrations drop relative to overall plasma expansion—crucial information when interpreting laboratory blood panels in the ER.
• Knowledge Checkpoint:
  • Detail the mismatch between red blood cell volume expansion and plasma volume expansion that leads to physiological hemodilution.
  • Explain why pregnant patients are in a baseline hypercoagulable state.
  • Discuss how these maternal-fetal changes affect standard diagnostic lab values in emergency presentations.

Module 2: Triage, Assessment, and Trauma in the Pregnant Patient

Assessment of the pregnant patient must be rapid, methodical, and tailored to altered maternal physiology. This module covers focused obstetric triage, the management of maternal cardiac arrest using Left Uterine Displacement (LUD), and the resuscitation of the pregnant trauma patient.

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Trauma In Pregnancy - Tips for Emergency Medicine

@regionstrauma42:486,061

Trauma In Pregnancy - Tips for Emergency Medicine

Trauma in pregnancy requires specialized emergency management due to unique physiological changes including 50% increased blood volume, supine hypotensive syndrome after 20 weeks, and altered organ positioning; critical considerations include early fetal monitoring, cautious interpretation of hypotension (patients may lose 2L before showing signs), and the five-minute rule for perimortem C-section (benefits both mother and fetus after 24 weeks), while maintaining standard trauma care principles

@regionstrauma · 42:48

• Why this video: This comprehensive, trauma-specific emergency medicine lecture addresses critical gaps highlighted in curriculum reviews. It teaches clinicians how to adjust trauma resuscitations for pregnant patients, emphasizing that maternal stabilization is the best way to stabilize the fetus.
• Knowledge Checkpoint:
  • Explain why a pregnant patient can lose up to 30-35% of blood volume before showing signs of shock, masking fetal distress.
  • Outline the primary and secondary survey adjustments needed for a pregnant trauma patient.
  • Recognize signs of placental abruption following blunt abdominal trauma.

How to perform CPR for Cardiac Arrest in Pregnancy with Left Uterine Displacement Technique?

@criticalcareift06:2482,552

How to perform CPR for Cardiac Arrest in Pregnancy with Left Uterine Displacement Technique?

In maternal cardiac arrest, the left uterine displacement technique is essential because the fetus can compress the aorta and inferior vena cava, reducing blood return to the mother's heart; effective CPR requires two-handed chest compressions at a rate of 100-120 per minute with one breath every six seconds, while prioritizing maternal survival as saving the mother is necessary to save the fetus; for neonatal resuscitation after delivery, initiate positive pressure ventilation at 1 breath every

@criticalcareift · 06:24

• Why this video: This video covers a crucial safety gap: managing maternal cardiac arrest. It demonstrates the mechanics of manual Left Uterine Displacement (LUD) to relieve aortocaval compression during chest compressions, ensuring adequate blood return to the heart.
• Knowledge Checkpoint:
  • Explain the anatomical rationale for Left Uterine Displacement (LUD) in pregnant patients beyond 20 weeks gestation.
  • Demonstrate the physical technique of performing continuous manual LUD during CPR without compromising chest compression depth or rate.
  • Understand how relief of aortocaval compression improves the efficacy of chest compressions during maternal cardiac arrest.

Obstetrics

@trotwoodfiretraining05:1425076

Obstetrics

Trauma is a leading cause of maternal death, with motor vehicle collisions accounting for 50% of perinatal mortality. Minor trauma is common due to loosened joints from pregnancy hormones and altered coordination. Major trauma is particularly dangerous due to increased vascular vascularity causing rapid deterioration. Trauma can cause placental separation, premature labor, spontaneous abortion, uterine rupture (50-75% fetal mortality), and fetal death. EMS must prioritize maternal care as saving

@trotwoodfiretraining · 05:14

• Why this video: Designed for first responders, this video covers pre-hospital assessment, common causes of trauma in pregnancy (such as motor vehicle collisions), and how altered center of gravity and loose joints increase fall risks.
• Knowledge Checkpoint:
  • Identify the primary mechanisms of maternal trauma (e.g., motor vehicle accidents, falls).
  • Recognize early signs of premature labor or uterine irritability following minor maternal trauma.
  • Structure a pre-hospital secondary assessment for a pregnant patient involved in an accident.

🔍 Independent Study Suggestion: While the videos above cover clinical triage and trauma extensively, the Obstetric Triage Education literature highlights specific formalized triage scales (like the Obstetric Triage Acuity Scale - OTAS). To supplement your learning, research how your local EMS agency or hospital emergency department incorporates OTAS or similar tools to systematically prioritize pregnant patients over non-pregnant patients with similar complaints.

Module 3: Normal Labor and Emergency Delivery

When transport is not possible, emergency department and EMS personnel must be prepared to assist with a normal vaginal delivery. This module details the clinical stages of labor and guides you step-by-step through assisting an uncomplicated delivery in the field.

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Labor and Delivery | Childbirth

@nucleusmedicalmedia03:0552,121,546

Labor and Delivery | Childbirth

Normal vaginal childbirth consists of three stages: Stage 1 involves cervical effacement and dilation over 12-19 hours, with symptoms including regular contractions, back pain, and possible rupture of membranes; Stage 2 begins at full cervical dilation (10cm) and lasts minutes to 3 hours, where the mother pushes while the baby's head rotates and molds during descent through the birth canal, followed by shoulder delivery; Stage 3 lasts 5-30 minutes as mild contractions help expel the placenta, al

@nucleusmedicalmedia · 03:05

• Why this video: This highly acclaimed 3D medical animation illustrates the three stages of normal vaginal delivery. It provides clear, accurate visuals of cervical dilation, fetal rotation through the birth canal, and the delivery of the placenta.
• Knowledge Checkpoint:
  • Identify the clinical parameters of the three distinct stages of normal labor.
  • Define "crowning" and understand the rotational movements of the fetal head during descent.
  • Describe the physiological detachment and delivery of the placenta.

OB assessment, delivery, and abnormal presentations

@ChicagoEMTTraining05:123,298

OB assessment, delivery, and abnormal presentations

The complete process of assisting with a normal vaginal delivery includes: preparing the perineum with non-alcohol wipes using front-to-back technique, identifying and managing nuchal cords by slipping them over the head or clamping if necessary, performing shoulder delivery with seesaw motions, maintaining proper positioning relative to the placenta, clearing the newborn's airway (mouth first, then nose), conducting initial Apgar assessment, applying two clamps (6 inches and 2 inches from baby)

@ChicagoEMTTraining · 05:12

• Why this video: This focused EMT training resource demonstrates how to set up an emergency delivery field and handle immediate delivery maneuvers, such as checking for and resolving a nuchal cord.
• Knowledge Checkpoint:
  • State the steps for preparing a clean or sterile perineal field in a pre-hospital environment.
  • Explain how to check for a nuchal cord as the head emerges, and how to safely slip it over the baby's head.
  • List the essential tools required in a standard emergency OB kit (clamps, scissors, bulb syringe).

OSCE OB Delivery

@utswsimulation876807:21342,359

OSCE OB Delivery

This video demonstrates the complete process of normal vaginal birth delivery, covering bed configuration for optimal visualization, perineal assessment techniques including monitoring tissue color changes from pink to white to determine optimal timing for applying external pressure, proper hand positioning to assist fetal head flexion and rotation, shoulder delivery maneuvers, and postpartum care including placental delivery signs, fundal massage to prevent hemorrhage, and laceration inspection

@utswsimulation8768 · 07:21

• Why this video: This structured clinical simulation demonstrates the precise physical support required during a vaginal delivery, including how to configure the bed, support the perineum to prevent tearing, and guide delivery of the shoulders.
• Knowledge Checkpoint:
  • Demonstrate how to apply gentle, controlled counter-pressure to the crowning fetal head to prevent rapid, traumatic expulsion.
  • Describe the upward and downward traction maneuvers used to facilitate delivery of the anterior and posterior shoulders.
  • Complete a thorough visual assessment of the perineum post-delivery.

Module 4: Hypertensive Crises and Postpartum Hemorrhage

This module focuses on the rapid identification and stabilization of two of the most common causes of maternal mortality: eclampsia (characterized by tonic-clonic seizures) and postpartum hemorrhage (PPH).

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Preeclampsia (Eclampsia) in Pregnancy Nursing Review: Pathophysiology, Symptoms, NCLEX

@RegisteredNurseRN26:481,131,406

Preeclampsia (Eclampsia) in Pregnancy Nursing Review: Pathophysiology, Symptoms, NCLEX

Preeclampsia is a hypertensive disorder of pregnancy occurring after 20 weeks gestation, characterized by new-onset hypertension (systolic >140 mmHg or diastolic >90 mmHg with two readings 4-6 hours apart) and proteinuria, which can progress to eclampsia (seizures). The pathophysiology involves abnormal placental development where spiral arteries fail to remodel properly, causing placental ischemia; the ischemic placenta releases toxic substances that damage maternal endothelial cells, leading t

@RegisteredNurseRN · 26:48

• Why this video: This comprehensive clinical lecture details the pathophysiology, multi-system signs, and nursing management of preeclampsia and eclampsia. It provides clear diagnostic parameters and outlines Magnesium Sulfate administration protocols.
• Knowledge Checkpoint:
  • Define the diagnostic thresholds for gestational hypertension, preeclampsia, and severe preeclampsia.
  • Recognize severe features of preeclampsia, including severe headache, visual disturbances, and epigastric pain.
  • State the primary therapeutic dosage and monitoring parameters for Magnesium Sulfate administration.

Nursing Simulation Scenario: Postpartum Hemorrhage

@montgomerycollege09:33498,407

Nursing Simulation Scenario: Postpartum Hemorrhage

Postpartum hemorrhage is a critical emergency requiring immediate multidisciplinary intervention, including uterine massage, IV fluid administration, bladder catheterization, and manual removal of retained placental tissue to restore uterine contraction and stop excessive bleeding.

@montgomerycollege · 09:33

• Why this video: This realistic simulation walks through a postpartum hemorrhage crisis. It shows the critical teamwork required for immediate diagnosis, uterine massage, bladder catheterization, and the coordination of uterotonic medications.
• Knowledge Checkpoint:
  • Define postpartum hemorrhage volumetrically (e.g., loss of >500ml after vaginal delivery).
  • Describe and demonstrate the physical technique of fundal massage to stimulate uterine contraction (reversing uterine atony).
  • Outline the collaborative steps in a PPH protocol (IV access, fluid resuscitation, medication administration).

Postpartum Hemorrhage Training Video

@adamcritcare07:26367,088

Postpartum Hemorrhage Training Video

Postpartum hemorrhage is a life-threatening emergency characterized by excessive bleeding after childbirth, requiring immediate intervention including uterine massage to firm the uterus, administration of medications such as oxytocin and tranexamic acid to promote contraction and reduce bleeding, and potential use of a Jackson-Pratt drainage device to remove retained products; prompt recognition of symptoms like dizziness, low blood pressure, and excessive bleeding, combined with systematic asse

@adamcritcare · 07:26

• Why this video: This video focuses on advanced management of postpartum hemorrhage in emergency and critical care settings. It covers pharmacological interventions (e.g., Oxytocin, Misoprostol, Tranexamic Acid) and advanced mechanical interventions.
• Knowledge Checkpoint:
  • Understand the "4 Ts" of PPH etiology: Tone, Tissue, Trauma, and Thrombin.
  • Identify the primary uterotonics used in the emergency setting, their routes of administration, and contraindications.
  • Describe the clinical indications for advanced mechanical stabilization (e.g., intrauterine balloon tamponade or bimanual compression) in refractory bleeding.

Module 5: Critical Delivery Complications and Maneuvers

This module covers high-risk, low-frequency obstetric complications where rapid, decisive physical maneuvers are required to save maternal and neonatal lives: shoulder dystocia, breech presentations, and prolapsed umbilical cords.

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Maneuvers for shoulder dystocia

@RawaMuhsin05:03286,617

Maneuvers for shoulder dystocia

Shoulder dystocia is an obstetric emergency requiring additional maneuvers beyond gentle lateral traction to deliver the anterior shoulder; the management protocol begins with McRoberts maneuver (abducting and hyperflexing the mother's thighs) combined with suprapubic pressure, which resolves approximately 90% of cases, followed by Rubin maneuver (vaginal finger pressure on the anterior shoulder), Wood screw maneuver (reversed finger pressure), posterior arm delivery, and all-fours position, wit

@RawaMuhsin · 05:03

• Why this video: This video demonstrates the essential maneuvers to resolve shoulder dystocia. It highlights the McRoberts maneuver (hyperflexing the mother's legs to her abdomen) and the application of suprapubic pressure.
• Knowledge Checkpoint:
  • Identify "turtle sign" as a key diagnostic indicator of shoulder dystocia.
  • Demonstrate the McRoberts maneuver and explain how it alters pelvic anatomy to release the impacted shoulder.
  • Distinguish between suprapubic pressure (indicated) and fundal pressure (strongly contraindicated, as it worsens impaction and risks uterine rupture).

Breech Delivery - A Systematic Approach

@obstetrics.education346611:45391,134

Breech Delivery - A Systematic Approach

Vaginal breech delivery is a high-risk procedure requiring a systematic approach divided into sequential stages: pelvis delivery with rotation from sacrum transverse to anterior position, leg delivery (footling breech requires cesarean), umbilicus delivery, trunk delivery with minimal tactile stimulation, arm delivery using sweeping maneuvers, and finally head delivery using the Moreau-Smellie-Bowditch maneuver or forceps if needed; critical timeframes include cesarean recommendation if breech n

@obstetrics.education3466 · 11:45

• Why this video: This video provides a systematic, highly educational guide to breech delivery. It covers breech classifications and details safe, hands-off descent techniques followed by controlled assist maneuvers.
• Knowledge Checkpoint:
  • Differentiate between frank, complete, and footling breech presentations.
  • Explain the "hands-off" principle during early breech descent to avoid stimulating premature fetal respiratory efforts.
  • Describe the Løvset maneuver for delivering the arms and the Mauriceau-Smellie-Veit (MSV) maneuver for delivering the head.

Maternal Newborn (OB)Nurse(RN)Student_Ricci 4th Ed. Full lecture Ch. 21_Labor and Birth at Risk_ 21

@LeahElliottOBNurseProfessor00:404,379

Maternal Newborn (OB)Nurse(RN)Student_Ricci 4th Ed. Full lecture Ch. 21_Labor and Birth at Risk_ 21

Emergency management of cord prolapse involves gloved hand placement on the presenting part to relieve cord compression, encouraging maternal knee-chest or hands-and-knees position to use gravity to lift the fetus off the cord, and immediate transport to operating room for emergency cesarean delivery. The cord should never be tucked back in as this can cause spasm and worsen compression.

@LeahElliottOBNurseProfessor · 00:40

• Why this video: This video addresses a key gap: active management of umbilical cord prolapse. It covers the mechanical relief of cord compression using a gloved, manual elevation technique alongside gravity-assisted maternal positioning.
• Knowledge Checkpoint:
  • Recognize umbilical cord prolapse during physical examination or upon sudden fetal bradycardia after rupture of membranes.
  • Demonstrate how to place a sterile gloved hand in the vagina to apply upward pressure on the fetal presenting part, relieving cord compression.
  • Identify maternal rescue positions (knee-chest or Trendelenburg) that use gravity to keep the fetus off the prolapsed cord during urgent transport.

Module 6: Immediate Newborn Care and Resuscitation

A critical component of any emergency delivery is care of the newborn. This module covers standard care for the vigorous infant and step-by-step implementation of the Neonatal Resuscitation Program (NRP) algorithm for the compromised neonate.

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Initial STEPS of Neonatal Resuscitation Program made super EASY!

@TalaTalksNICU23:4859,631

Initial STEPS of Neonatal Resuscitation Program made super EASY!

The Neonatal Resuscitation Program (NRP) is the gold standard for neonatal resuscitation in delivery rooms, emphasizing that most newborns need only breathing support rather than cardiac intervention. Before delivery, healthcare providers must answer four key questions: gestational age, amniotic fluid condition, maternal risk factors, and umbilical cord management (RAGU). A baby can stay on the mother's chest if it meets three criteria: term status (>37 weeks), good muscle tone, and effective br

@TalaTalksNICU · 23:48

• Why this video: This exceptionally clear, step-by-step tutorial breaks down the Neonatal Resuscitation Program (NRP) guidelines. It explains how to transition from the initial steps of drying and stimulating to positive pressure ventilation (PPV) when needed.
• Knowledge Checkpoint:
  • State the three initial questions to assess a newborn at birth: Term gestation? Good muscle tone? Breathing or crying?
  • Demonstrate the correct sequence of immediate care: warm, position airway, clear secretions (if obstructed), dry, and stimulate.
  • Identify the clinical indications for starting Positive Pressure Ventilation (PPV) within the first 60 seconds of life ("The Golden Minute").

How to resuscitate a newborn baby

@MedicalAidFilmsFilmsForLife20:04421,768

How to resuscitate a newborn baby

Neonatal resuscitation is a time-sensitive emergency procedure performed when a newborn fails to initiate breathing at birth, following a systematic approach: first, keep the baby warm by drying and wrapping them in warm towels; second, assess the baby's condition by checking color, tone, breathing, and heart rate; third, open the airway using the head tilt chin lift or jaw thrust maneuver; fourth, provide five inflation breaths using a bag and mask, ensuring visible chest rise; fifth, if the he

@MedicalAidFilmsFilmsForLife · 20:04

• Why this video: This video details the equipment setup, ventilation techniques, and clinical decision-making needed when a newborn does not breathe spontaneously, presenting the concepts in a highly visual, accessible format.
• Knowledge Checkpoint:
  • Describe how to choose the correct neonatal mask size and achieve an effective seal for ventilation.
  • Understand the ventilation rate (40 to 60 breaths per minute) and how to evaluate adequacy via chest rise and heart rate.
  • Outline when to progress from ventilation to chest compressions based on heart rate thresholds.

Joy James teaches neonatal resuscitation skills in the clinical simulation centre

@GlamorganUniversity08:34384,544

Joy James teaches neonatal resuscitation skills in the clinical simulation centre

Neonatal resuscitation follows a systematic protocol: first, place the baby in the neutral position with the nose toward the ceiling to ensure open airways; second, deliver five inflation breaths over 2-3 seconds at 20-30 cm pressure to clear lung fluid; third, if the baby isn't breathing independently and heart rate drops to 60 bpm or below, initiate chest compressions at a 3:1 ratio with ventilation; fourth, reassess every 30 seconds; fifth, if the baby remains unresponsive, transition to stan

@GlamorganUniversity · 08:34

• Why this video: This practical clinical simulation demonstrates how to position the newborn's neck in the "sniffing" position and deliver inflation breaths using a bag-valve-mask.
• Knowledge Checkpoint:
  • Position a neonate's head in the neutral or "sniffing" position to ensure airway patency, avoiding hyperextension or hyperflexion.
  • Perform the MR. SOPA airway troubleshooting steps if chest rise is inadequate during PPV.
  • Determine APGAR scores at 1 and 5 minutes post-delivery.

Course Map

This flowchart maps the recommended learning progression and shows how earlier concepts build into advanced clinical management.

Key People Index

• Dr. Sakshi Arora Hans (Featured in Module 1)
  • Context: Obstetrician, author, and medical educator specializing in high-yield physiological and clinical concepts for medical exams and clinical practice.
• Dr. Raj Sherman (Featured in Module 2)
  • Context: Canadian Emergency Physician and clinical leader; provides instruction on the triage priority models used to categorize emergency patient presentations.
• Joy James (Featured in Module 6)
  • Context: Senior midwifery lecturer and clinical simulation educator, specializing in hands-on clinical training for neonatal resuscitation.

Final Self-Assessment

Complete this comprehensive self-assessment checklist after finishing all modules:

• Maternal Physiology: Can you identify the normal alterations in a pregnant patient's vital signs, including baseline heart rate increases and systemic blood pressure drops?
• Maternal Resuscitation: Can you perform manual Left Uterine Displacement (LUD) to relieve aortocaval compression during a cardiac arrest scenario?
• Trauma Management: Do you understand why a pregnant trauma patient can experience significant internal blood loss before demonstrating classic signs of hypovolemic shock?
• Uncomplicated Delivery: Are you prepared to guide a normal vaginal delivery, including checking for a nuchal cord and supporting the perineum?
• Postpartum Hemorrhage (PPH): Can you identify the symptoms of severe PPH, perform a proper fundal massage, and outline the standard uterotonic medications?
• Preeclampsia/Eclampsia: Can you identify the severe features of preeclampsia and state the correct administration and monitoring steps for Magnesium Sulfate?
• Shoulder Dystocia: Can you perform the McRoberts maneuver and apply suprapubic pressure? Do you understand why fundal pressure is contraindicated?
• Breech Presentations: Do you understand the "hands-off" descent principle and how to safely assist a breech delivery?
• Cord Prolapse: Can you describe the manual elevation technique used to relieve umbilical cord compression during urgent transfer?
• Neonatal Resuscitation (NRP): Can you perform the initial resuscitation steps (warm, position, dry, stimulate) and identify when to initiate positive pressure ventilation (PPV)?