Intern Ready: Ob/Gyn

Intern Ready: Ob/Gyn

By Lucy Brown, M.D.ScienceMedicineHealth & FitnessEducationLife Sciences
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Intern Ready: Ob/Gyn episodes

  • Before Your First: Induction of Labor

    Induction of labor now accounts for roughly 1 in 3 deliveries in the U.S., so as an intern you'll be part of inductions almost every shift, whether scheduled or a same-day plan from triage. In this episode, Dr. Veena Bhagavathi walks through who gets induced and why, how to use the Bishop score, the cervical ripening options, what to do once the cervix is favorable, and how long to wait before calling an induction "failed."

    Indications & Contraindications

    • Elective induction means induction at 39 weeks without a medical indication. 39 weeks is the cutoff because the neonatal risks of late-preterm and early-term birth are well established.
    • ARRIVE trial: in low-risk nulliparas, induction at 39 0/7–39 4/7 weeks reduced cesarean delivery (18.6% vs 22.2%, RR 0.84) and hypertensive disorders of pregnancy (9.1% vs 14.1%, RR 0.64), with no significant difference in neonatal outcomes.
    • Induction between 41 0/7 and 42 0/7 weeks can be considered; induction by 42 6/7 weeks is recommended given increased perinatal morbidity and mortality beyond that.
    • Don't defer delivery to 39 weeks if there's a medical or obstetric indication for earlier delivery — always run the risk-benefit calculation.
    • Medically indicated induction, maternal: chronic HTN, gestational HTN, preeclampsia (with or without severe features), diabetes.
    • Medically indicated induction, fetal: growth restriction, multiple gestation, PPROM/PROM.
    • PPROM delivery timing has an interim ACOG update (Committee Opinion 831). Pull the current ACOG page before finalizing a plan, and discuss and document the added neonatal risk of prolonged expectant management with unknown or positive GBS status.
    • Contraindications are essentially any contraindication to vaginal delivery: placenta or vasa previa, malpresentation or non-cephalic lie, prior classical cesarean, active herpes infection, and severe fetal or maternal compromise requiring faster delivery.

      • The Bishop Score

      • Dilation, effacement, and station are scored 0–3; consistency and position are scored 0–2. Total range: 0–13.
      • Score ≥8 → favorable ("ripe") cervix, with a good chance of vaginal delivery on induction.
      • Score ≤6 → unfavorable ("unripe") cervix, with a lower chance of vaginal delivery; cervical ripening is indicated.
      • A simplified Bishop score using only dilation, station, and effacement may be just as predictive — a simplified score of 5 performs similarly to a full score >8.
      • Ask the patient if she's had a cervical exam before, or what her prior inductions looked like. Parity and history both factor in, and the vast majority of people undergoing induction will need some form of cervical ripening.

        • Cervical Ripening Methods

        • Before using prostaglandins, check the contraction pattern (no more than 3 contractions in 10 minutes, averaged over 30 minutes) and consider fetal status (decels, severe FGR).
        • Foley balloon — mechanical. Supplies: speculum, ring forceps, betadine swabs, flushes, chux.
        • Cook catheter — mechanical double-balloon device, sometimes used with a stylet.
        • Misoprostol (PGE₁) — oral 20–25 mcg q2h, or vaginal 25 mcg q3–6h (ACOG CPG No. 9, 2025); can be given vaginally or buccally. AVOID in prior cesarean or uterine surgery entering the cavity (e.g., myomectomy) because of uterine rupture risk.
        • Dinoprostone (PGE₂) — vaginal insert (Cervidil) or gel.
        • Osmotic dilators — mechanical alternative, less commonly first-line.
        • Outpatient cervical ripening — an option in select low-risk candidates; discuss with your team.
        • Membrane stripping/sweeping — a gloved finger sweeps over the membranes (requires partial cervical dilation) and may release natural prostaglandins.
        • If a patient presents already ruptured and not dilated, and no balloon is appropriate, go to buccal or vaginal misoprostol, or straight to Pitocin.

          • Active Labor Management (Favorable Cervix)

          • Pitocin (synthetic oxytocin) — titrated to achieve adequate contractions. Low- vs high-dose protocols vary by institution.
          • AROM (amniotomy) — a small hole is made in the amniotic sac once the cervix is dilated and thinned and the fetal head has descended into the pelvis. Most patients labor within hours of rupture, and early amniotomy is also an accepted strategy.

            • Timeline & Failed Induction

            • Early labor: allow up to 24 hours or longer for patients induced at 39 weeks.
            • Give oxytocin at least 12–18 hours after membrane stripping before declaring an induction attempt failed.
            • Median L&D stay in ARRIVE was 20 hours (induction) vs 14 hours (expectant management), so set expectations with patients and staff that inductions, especially in nulliparas, can take a long time.
            • Not all inductions end in vaginal delivery, and the clinical picture can keep changing — reassess continuously.

              • History Taking on Admission

              • ROS and medical/surgical history.
              • OB/GYN history — prior cesareans, prior labor complications, STI history.
              • Prenatal care review — e.g., GBS status (does she need intrapartum penicillin?).
              • Plans after delivery — contraception and feeding plans.
              • Sexual history and safety — STIs (including last Pap), alcohol/drug/tobacco use (ask the partner to step out for this part).
              • For a scheduled induction you may already know most of this from clinic, but always confirm.

                • Rapid-Fire Pearls

                • Elective induction at 39 weeks in low-risk nulliparas lowers cesarean and hypertensive-disease rates — it's not just "convenience."
                • A favorable Bishop score (≥8) predicts a good chance of vaginal delivery; most patients will need cervical ripening first.
                • Avoid misoprostol after prior cesarean or uterine surgery entering the cavity.
                • Check the contraction pattern before and during prostaglandin use.
                • Allow 12–18 hours of oxytocin after membrane stripping, and up to 24+ hours of early labor, before calling an induction "failed."
                • Inductions, especially in nulliparas, can take a long time, and the picture can change throughout.

                  • Resources:

                  • ACOG Committee Opinion No. 831 — Medically Indicated Late-Preterm and Early-Term Deliveries (2021; interim update on PPROM delivery timing)
                  • Grobman WA et al. (ARRIVE trial). "Labor Induction versus Expectant Management in Low-Risk Nulliparous Women." N Engl J Med. 2018;379:513–523
                  • ACOG Clinical Practice Guideline No. 9 — Cervical Ripening in Pregnancy (2025)
                  • Ayala NK, Rouse DJ. "Failed Induction of Labor." Am J Obstet Gynecol. 2024;230(3S):S769–S774

                    • Topics to Review Over Time:

                    • Oxytocin titration protocols (low- vs high-dose) and recognizing tachysystole
                    • Interpreting category II fetal heart tracings during induction
                    • Induction in patients with a prior cesarean (TOLAC)
                    • Management of PPROM and GBS prophylaxis
                    • Failed induction and the decision to proceed to cesarean

                      • About the Speakers:

                      Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency.

                      Guest Speaker: Veena Bhagavathi, MD – PGY-2 in the Johns Hopkins Gyn/Ob residency program. Originally from New Jersey, she attended Rutgers' Robert Wood Johnson Medical School before moving to Baltimore. Her interests include global health, family planning and abortion care, and adolescent health.

                      Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

                      19 min
                    • Before Your First: IUD Insertion

                      Placing an IUD is one of the most common procedures you'll be asked to help with as an intern — and one of the easiest to feel unprepared for if you haven't reviewed the device differences ahead of time. In this episode, Dr. Lillian Chen breaks down the five IUDs you'll encounter, how their insertion mechanics differ, what changes in the postpartum and postabortion setting, and the high-yield points you're likely to be tested on.

                      IUD Types at a Glance

                      • Mirena — LNG-IUD, 52 mg levonorgestrel, FDA-approved for 8 years (effective 8+ years), 4.4 mm tube, 6–10 cm uterine sound range. Lighter bleeding/amenorrhea common. FDA-approved for heavy menstrual bleeding (HMB).
                      • Liletta — LNG-IUD, 52 mg levonorgestrel, FDA-approved for 8 years (effective 8+ years), 4.8 mm tube, 6–10 cm uterine sound range. Lighter bleeding/amenorrhea common. Uses a different inserter than the Bayer products.
                      • Kyleena — LNG-IUD, 19.5 mg levonorgestrel, FDA-approved for 5 years, 3.8 mm tube, 6–10 cm uterine sound range. Less bleeding and less amenorrhea than Mirena; smaller frame.
                      • Skyla — LNG-IUD, 13.5 mg levonorgestrel, FDA-approved for 3 years, 3.8 mm tube, 6–10 cm uterine sound range. Regular menses more common; good option for smaller uterine cavities.
                      • Paragard — Copper T380A (hormone-free), FDA-approved for 10 years (effective 12+ years), ~4.7 mm tube, 6–9 cm uterine sound range. Heavier menses/cramping.

                        • Insertion Pearls

                        • Mirena, Kyleena, and Skyla use the Bayer one-handed slider system and have very similar deployment mechanics.
                        • Liletta has a unique loading sequence and should be reviewed separately before insertion.
                        • Paragard requires loading the arms into the insertion tube and is often considered the least intuitive inserter for trainees.
                        • Always confirm fundal placement before release.
                        • Routine antibiotic prophylaxis is not recommended.

                          • Postplacental & Postabortion Pearls

                          • Immediate postpartum insertion is safe and effective but has higher expulsion rates.
                          • IUDs can be placed immediately after first- or second-trimester abortion when no contraindication exists.
                          • Counsel patients that expulsion risk is higher after postpartum placement.

                            • Board-Style High-Yield Points

                            • Copper IUD is the most effective form of emergency contraception.
                            • LNG-IUDs reduce menstrual blood loss and dysmenorrhea.
                            • Mirena is FDA-approved for heavy menstrual bleeding.
                            • Amenorrhea rates increase with higher-dose LNG-IUDs.
                            • Same-day insertion is appropriate when pregnancy can reasonably be excluded.

                              • Resources:

                              • Mirena — Insertion and Removal
                              • Kyleena — Insertion and Removal
                              • Skyla — Insertion and Removal
                              • Liletta — Insertion and Removal
                              • Paragard — Placement and Removal
                              • ACOG Paragard Insertion Animation
                              • ACOG Kyleena Insertion Animation

                                • Topics to Review Over Time:

                                • IUD removal technique and management of a lost or malpositioned string
                                • Managing IUD-related bleeding and cramping complaints
                                • Contraindications and medical eligibility criteria (US MEC) for IUD placement
                                • Counseling on non-contraceptive benefits (HMB, dysmenorrhea) vs. side effects
                                • Difficult insertions: cervical stenosis, nulliparous patients, and adjunct techniques

                                  • About the Speakers:

                                  Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency.

                                  Guest Speaker: Lillian Chen, MD, MPH – Academic generalist at Johns Hopkins University with a particular interest in medical education, contraception, and family planning.

                                  Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

                                  15 min
                                • Before Your First: Preeclampsia Workup

                                  Preeclampsia complicates roughly 10% of pregnancies and accounts for up to 9% of pregnancy-related deaths in the U.S. — which makes it one of the highest-stakes diagnoses you'll manage as an intern. In this episode, Dr. Anna Jarvis walks through the hypertensive spectrum, how to get the diagnosis right, when to worry about severe features or HELLP syndrome, how to rule out the mimics, and how fast you need to move when things get acute.

                                  Resources:

                                  • ACOG Practice Bulletin No. 222 — Gestational Hypertension and Preeclampsia (2020)
                                  • Magee LA, Nicolaides KH, von Dadelszen P. "Preeclampsia." N Engl J Med. 2022;386:1817–1832
                                  • Sibai BM. "Imitators of Severe Preeclampsia." Obstet Gynecol. 2007;109(4):956–66
                                  • ACOG/SMFM Practice Advisory — Low-Dose Aspirin Use for Prevention of Preeclampsia (2021, reaffirmed)

                                    • Topics to Review Over Time:

                                    • Chronic hypertension in pregnancy: antihypertensive selection and BP targets
                                    • Low-dose aspirin prophylaxis — who qualifies and when to start
                                    • Eclampsia: seizure management and post-seizure stabilization
                                    • Postpartum antihypertensive management and medication safety in lactation
                                    • Long-term cardiovascular risk counseling after a hypertensive pregnancy disorder

                                      • About the Speakers:

                                      Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency.

                                      Guest Speaker: Anna Cardall Jarvis, MD – First-year Maternal-Fetal Medicine fellow at The Johns Hopkins Hospital, where she completed her residency in Obstetrics and Gynecology. Her clinical and research interests focus on hypertensive disorders of pregnancy, maternal cardiovascular disease, and improving outcomes for pregnant patients with chronic medical conditions. She is also actively involved in medical education, teaching and mentoring medical students and residents.

                                      Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

                                      22 min
                                    • Before Your First: Gyn Onc Clinic

                                      Gynecologic oncology clinic can feel intimidating for a new intern — the patients are complex and the terminology is dense. In this episode, Dr. Liang breaks down the three visit types you'll encounter (new patient, chemo clearance, and surveillance), what to prechart, and what your role is as the resident in each one.

                                      Visit Type 1: New Patient Visits

                                      BEFORE CLINIC — PRECHARTING

                                      • Ask: Why are they here?
                                        • Confirmed cancer diagnosis (pathology in hand)?
                                        • Concern for cancer only — no pathology yet?
                                        • Seeking second opinion after treatment elsewhere?
                                        • Hereditary cancer syndrome (Lynch, BRCA)?
                                        • HPI — how did the patient present? What symptoms?
                                        • Workup by primary cancer type:
                                          • Uterine: endometrial sampling, TVUS, CT abdomen/pelvis
                                          • Ovarian: CA-125, imaging
                                          • Cervical/vulvar: Pap history, colposcopy, biopsies, LEEP, CKC
                                          • Medical & surgical history — comorbidities, medications, prior abdominal surgeries
                                          • Family history — relatives affected, cancer type, age at diagnosis
                                          • Preventive screening — Pap, mammogram, colonoscopy up to date?

                                            • DURING THE VISIT

                                            • Ask the patient: what is their understanding of why they're here and of next steps?
                                            • Confirm and fill in gaps from chart review
                                            • Assess functional status → ECOG performance status (impacts candidacy for surgery/treatment)
                                            • Exam: heart, lungs, abdomen — defer pelvic exam until attending is present
                                            • "The tissue is the issue" — cancer cannot be confirmed without pathology (endometrial sampling, biopsy, or surgical pathology)

                                              • Visit Type 2: Chemo Clearance Visits

                                              KEY TERMINOLOGY

                                              • Cytotoxic agents (e.g., carboplatin, paclitaxel) — target rapidly dividing cells
                                              • Immunotherapy / checkpoint inhibitors (e.g., pembrolizumab) — immune system targets cancer
                                              • PARP inhibitors (e.g., olaparib) — prevent DNA repair; used in ovarian cancer
                                              • Hormonal therapy (e.g., letrozole, an aromatase inhibitor) — for ER/PR+ tumors
                                              • Adjuvant — chemo after surgery (most common)
                                              • Neoadjuvant — chemo before surgery (to downsize disease; often used in advanced ovarian cancer)
                                              • Maintenance therapy — additional treatment after initial surgery + chemo to delay recurrence (PARP inhibitors, bevacizumab)

                                                • BEFORE THE VISIT — FOCUSED CHART REVIEW

                                                • Pull up last clinic note → one-liner + oncologic summary
                                                • Cancer type, stage, date of diagnosis
                                                • Prior surgeries and procedures
                                                • Current regimen — cycle #, date of last treatment
                                                • First regimen or has there been a prior line?
                                                • Review prior side effects and tolerance
                                                • Labs: ANC, Hgb, Plts, Cr, electrolytes, tumor markers
                                                • Imaging: no evidence of disease? Partial response? Progression?

                                                  • DURING THE VISIT

                                                  • How did they tolerate the last cycle?
                                                  • Ask about previously reported side effects — better or worse? Any new ones?
                                                  • Look up key side effects for their specific regimen ahead of time
                                                  • Brief ROS: fatigue, appetite, nausea/vomiting
                                                  • Exam: heart, lungs, abdomen
                                                  • Goal: confirm labs are acceptable, patient is tolerating treatment, and disease is not progressing. You are not expected to manage the regimen as a resident.

                                                    • Visit Type 3: Surveillance Visits

                                                    PURPOSE

                                                    • Patients who have completed treatment and currently have no evidence of disease (NED)
                                                    • Monitor for signs of recurrence — frequency and duration vary by cancer type and stage
                                                    • Example: early-stage endometrial cancer → H&P every 3–6 months for first 2–3 years, then every 6–12 months up to 5 years

                                                      • BEFORE & DURING THE VISIT

                                                      • Use last clinic note: cancer type, surgeries/treatments, duration of NED
                                                      • Any chronic side effects from treatment?
                                                      • Any tumor markers or imaging being followed?
                                                      • During visit: ask about any new symptoms
                                                      • ROS: weight changes, appetite, abdominal pain, bladder/bowel function, vaginal bleeding

                                                        • Resources:

                                                        • UpToDate — great starting point for any topic overview
                                                        • NCCN (free account at nccn.org) — guidelines for staging, treatment, and surveillance

                                                          • Topics to Review Over Time:

                                                          • Endometrial cancer: risk factors, surgical staging, fertility-sparing management
                                                          • Ovarian cancer: approach to the complex adnexal mass, tumor markers, surgical staging
                                                          • Cervical cancer: risk factors, Pap smear guidelines, colposcopy, LEEP, cold knife cone
                                                          • Vulvar cancer: risk factors and treatment options
                                                          • Hereditary syndromes: Lynch and BRCA — surveillance guidelines and risk-reducing surgery

                                                            • About the Speakers:

                                                            Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency.

                                                            Guest Speaker: Angela Liang, MD – OB/GYN resident at The Johns Hopkins Hospital. She will be starting gynecologic oncology fellowship at the University of Pennsylvania.

                                                            Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

                                                            17 min
                                                          • Before Your First: Infertility Clinic

                                                            Walking into your first infertility clinic visit and not sure what to expect? In this episode, Dr. Valdez-Sinon walks through the definition of infertility, how to take a thorough history for both partners, the key workup for ovulatory, tubal, uterine, and male factors, and when to refer to REI.

                                                            Definition

                                                            What is infertility?

                                                            • Failure to achieve pregnancy after 12 months of regular unprotected intercourse — for patients under 35
                                                            • Shorten to 6 months for patients 35 and older
                                                            • Anyone 40+ should be seen as soon as they start trying — don't wait
                                                            • Immediate evaluation warranted for:
                                                              • Oligomenorrhea or amenorrhea
                                                              • Known uterine or tubal disease
                                                              • Stage III/IV endometriosis
                                                              • Resource: ACOG Committee Opinion No. 781 and ASRM guidelines

                                                                • History & Exam

                                                                HISTORY — PATIENT

                                                                • Comprehensive medical and surgical history
                                                                • Menstrual history — are cycles regular? (regular cycles suggest ovulation, but ~1/3 of regular cyclers can still be anovulatory)
                                                                • Full GYN history — pelvic infections, STIs, known fibroids, endometriosis
                                                                • Prior pregnancies with previous partners? (establishes primary vs. secondary infertility)
                                                                • Ask about: thyroid disease, galactorrhea, hirsutism, pelvic/abdominal pain, dyspareunia
                                                                • Family history: developmental delay, early menopause, reproductive problems
                                                                • Social history: tobacco, alcohol, recreational drugs

                                                                  • HISTORY — PARTNER

                                                                  • Obtain medical and reproductive history — pregnancy takes two
                                                                  • Prior pregnancies with previous partners?
                                                                  • Intercourse frequency — ideally unprotected sex ~2x/week

                                                                    • PHYSICAL EXAM

                                                                    • Vitals, weight and BMI — extremes affect fertility
                                                                    • Thyroid exam; breast exam (look for galactorrhea if indicated)
                                                                    • Signs of androgen excess — acne, hirsutism, male-pattern hair
                                                                    • Pelvic exam — uterine size, shape, mobility; adnexal masses or tenderness

                                                                      • Ovarian & Ovulatory Evaluation

                                                                      COMMON CAUSES

                                                                      • PCOS — most common cause of ovulatory-related infertility
                                                                      • Primary ovarian insufficiency (POI)
                                                                      • Thyroid disease, hyperprolactinemia

                                                                        • WORK-UP

                                                                        • Mid-luteal progesterone — obtain ~day 21 of a 28-day cycle; value >3 ng/mL suggests ovulation
                                                                        • For PCOS evaluation: LH, FSH, testosterone
                                                                        • Thyroid function studies and prolactin as indicated
                                                                        • Ovarian reserve:
                                                                          • Antral follicle count on early-cycle ultrasound
                                                                          • AMH — value <1 ng/mL suggests diminished ovarian reserve
                                                                          • A low AMH does not mean infertility — it only takes one egg. AMH estimates ovarian reserve and responsiveness to gonadotropins for IVF/oocyte preservation.

                                                                            • TREATMENT FOR ANOVULATION

                                                                            • Ovulation induction with clomiphene (estrogen receptor antagonist) or letrozole (aromatase inhibitor)

                                                                              • Tubal Evaluation

                                                                              • HSG (hysterosalpingogram) — gold standard for tubal patency
                                                                              • Radio-opaque dye injected through cervix; X-ray visualizes "fill and spill" through tubes
                                                                              • Low positive predictive value — non-patency needs follow-up
                                                                              • Hydrosalpinx: salpingectomy often recommended before IVF — fluid impairs implantation
                                                                              • Known tubal factor → IVF required for conception

                                                                                • Uterine Evaluation

                                                                                • Look for: polyps, fibroids, septum, adhesions (synechiae) — >16% of patients with infertility have a uterine abnormality on sono
                                                                                • Saline infusion sonogram (SIS) — preferred over standard TVUS; saline distends the cavity to reveal lesions
                                                                                • 3D ultrasound can also be helpful
                                                                                • Follow-up hysteroscopy — both diagnostic and therapeutic

                                                                                  • Sperm / Male-Factor Evaluation

                                                                                  • Male factor contributes to infertility in 40–50% of couples — do not overlook
                                                                                  • Semen analysis — gold standard; order early in the evaluation
                                                                                  • At-home semen tests available as a screening step if insurance or access is a barrier

                                                                                    • Quick Recap & Intern Pearls

                                                                                    BUCKETS OF INFERTILITY

                                                                                    • Female factor (~ovarian, tubal, or uterine)
                                                                                    • Male factor (40–50% of couples)
                                                                                    • Unexplained (~30% of couples)
                                                                                    • Note: "Female factor" and "male factor" are simplifications — anatomy and gender identity vary. Tailor evaluation to each patient and partnership.

                                                                                      • DO NOT ROUTINELY ORDER (PER ASRM)

                                                                                      • Prolactin (unless indicated), karyotype, thrombophilia panel, endometrial biopsy

                                                                                        • INTERN CLINIC PEARLS

                                                                                        • Get a thorough history and physical — that is the most important part
                                                                                        • Walk patients through the "journey of the egg" framework: ovary → fallopian tube → uterus
                                                                                        • Use diagrams to explain ovulatory, tubal, and uterine factor concepts
                                                                                        • If the patient meets infertility criteria based on duration of attempts → refer to REI

                                                                                          • Since the recording of this episode, Polycystic Ovary Syndrome (PCOS) underwent a name change to now be referred to as Polyendocrine Metabolic Ovarian Syndrome (PMOS). The new naming of the disease better encompasses the endocrine and metabolic effects of the disease beyond the ovary.

                                                                                          Resources:

                                                                                          • ACOG Committee Opinion No. 781: Infertility Workup for the Women's Health Specialist
                                                                                          • ASRM Practice Committee Documents
                                                                                          • UpToDate: Overview of Infertility

                                                                                            • About the Speakers:

                                                                                            Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency.

                                                                                            Guest Speaker: Arielle Valdez-Sinon, MD, PhD – Gyn/Ob chief resident at Johns Hopkins Hospital. She will be starting fellowship in Reproductive Endocrinology at Johns Hopkins in Fall 2026. She has an interest in reproductive surgery with the use of minimally invasive techniques to improve fertility outcomes.

                                                                                            Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

                                                                                            13 min
                                                                                          • Before Your First: Hysteroscopy

                                                                                            Headed into the OR for your first hysteroscopy? In this episode, we walk through everything you need to know before you scrub in — from indications and pre-op preparation to OR equipment, distension media, fluid deficit management, and how to handle complications when they arise.

                                                                                            I. Introduction & Learning Goals

                                                                                            Purpose: Guidance for an intern's first hysteroscopy in the OR.

                                                                                            Objectives: Review indications, pre-op preparation, OR setup/equipment, fluid media, and complications.

                                                                                            II. Indications for Hysteroscopy

                                                                                            Diagnostic Hysteroscopy:

                                                                                            • Abnormal uterine bleeding (AUB) or postmenopausal bleeding
                                                                                            • Infertility workup
                                                                                            • Evaluation of abnormal imaging findings

                                                                                              • Operative Hysteroscopy:

                                                                                              • Polypectomy (removal of polyps)
                                                                                              • Myomectomy (removal of submucosal fibroids)
                                                                                              • Septum resection
                                                                                              • Lysis of adhesions (Asherman syndrome)
                                                                                              • Foreign body removal (e.g., "lost" IUD)

                                                                                                • III. Pre-Operative Preparation

                                                                                                Chart Review Checklist:

                                                                                                • Indication: Understand the clinical reason for the procedure
                                                                                                • Imaging (US/MRI): Confirm uterine size (to avoid over-dilating) and location of pathology
                                                                                                • Comorbidities: Check cardiac, renal, and pulmonary history to set fluid management thresholds
                                                                                                • Cervical History: Assess risk for stenosis (prior procedures or menopause)
                                                                                                • Menstrual Cycle: Check current phase (bleeding can obscure visualization)

                                                                                                  • Patient Counseling (Benefits & Risks):

                                                                                                  • Benefits: Superior diagnostic sampling and therapeutic symptom relief
                                                                                                  • Standard Risks: Pain, bleeding, infection (low risk)
                                                                                                  • Specific Risks: Uterine perforation (may require laparoscopy if energy was used or if there is concern for bowel injury)

                                                                                                    • IV. Equipment & OR Setup

                                                                                                    The Hysteroscope Components:

                                                                                                    • Telescope: The lens (0-degree for forward viewing vs. 30-degree for lateral angles)
                                                                                                    • Sheaths: Inner and outer sheaths to house the telescope and allow fluid flow
                                                                                                    • Inflow/Outflow Ports: For fluid delivery and drainage (use under-the-butt drapes to catch fluid for deficit calculation)
                                                                                                    • Light Source: Warning — becomes extremely hot; keep away from drapes/patient
                                                                                                    • Camera System & Monitor
                                                                                                    • Working Channel: For operative instruments (graspers, scissors)

                                                                                                      • V. Distension Media (Fluids)

                                                                                                      Isotonic Solutions (Preferred):

                                                                                                      • Normal Saline: Compatible with bipolar electrosurgery; same osmolality as blood

                                                                                                        • Hypotonic Solutions:

                                                                                                        • Glycine (1.5%), Sorbitol (3%), Mannitol (5%)
                                                                                                        • Used only for monopolar surgery; higher risk of hyponatremia

                                                                                                          • Fluid Deficit Management:

                                                                                                          • Definition: The difference between fluid into the uterus vs. fluid recovered
                                                                                                          • ACOG Threshold: Max 2,500 mL for isotonic; however, many surgeons stop at 1,500 mL (or 750–1,000 mL for high-risk patients)

                                                                                                            • VI. Procedural Steps & Tips

                                                                                                            • Cervical Dilation: Can use mechanical dilators or "hydrodilation" using fluid pressure through the scope
                                                                                                            • Tenaculum Tip: Take a "sturdy bite" of the cervix to prevent tearing/lacerations
                                                                                                            • Pressure Management: Keep intrauterine pressure lower than the patient's Mean Arterial Pressure (MAP) to limit fluid extravasation into the body

                                                                                                              • VII. Complications

                                                                                                              • Uterine Perforation: Often occurs during dilation; recognized by a "loss of resistance"
                                                                                                              • Fluid Overload: Can lead to hyponatremia, distributive shock, or flash pulmonary edema
                                                                                                              • Hemorrhage: More common in operative cases (3% for myomectomy); manage with massage, uterotonics, or intrauterine balloons
                                                                                                              • Vasovagal Reaction: Can occur during cervical manipulation or distension
                                                                                                              • Gas Embolism: Rare; more common with older CO₂ distension methods

                                                                                                                • Resources:

                                                                                                                • ACOG Technology Assessment: Hysteroscopy
                                                                                                                • UpToDate: Hysteroscopy – Managing Fluid and Gas Distending Media
                                                                                                                • AAGL – Advancing Minimally Invasive Gynecology Worldwide

                                                                                                                  • About the Speakers:

                                                                                                                  Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency.

                                                                                                                  Guest Speaker: Mahima Krishnamoorthi, MD – Gyn/Ob resident at Johns Hopkins Hospital. She attended Stanford University for undergrad and graduated from the Johns Hopkins School of Medicine.

                                                                                                                  Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

                                                                                                                  19 min
                                                                                                                • Before Your First: Day With Fetal Therapy

                                                                                                                  Fetal therapy is a subspecialty of maternal-fetal medicine focused on treating fetal disease before birth — from prenatal cures (anemia, TTTS) to improving outcomes (myelomeningocele, CDH), optimizing conditions at birth, and transplacental therapy (SVT, congenital heart block). In this episode, Dr. Michelle Kush walks us through the major fetal therapy procedures you may encounter as an OB/GYN resident and what your role will be.

                                                                                                                  Topics Covered:

                                                                                                                  • What Is Fetal Therapy? – Subspecialty of MFM treating fetal conditions before birth. Contact the fetal therapy team at 844-543-3825.
                                                                                                                  • Fetal Anemia and Intrauterine Transfusion
                                                                                                                    • Busiest fetal transfusion center in the Mid-Atlantic (600+ transfusions to date).
                                                                                                                    • Most common indications: alloimmunization, parvovirus infection, hydrops/hereditary spherocytosis.
                                                                                                                    • Performed on L&D once fetus reaches viability, with betamethasone course completed.
                                                                                                                    • Risks: preterm labor, PROM, fetal bradycardia, emergent delivery (<1%).
                                                                                                                    • General care path: arrive → H&P → OB anesthesiology → NPO, IVF, continuous fetal monitoring → transfusion (usually in triage room) with OR, anesthesiology, and NICU on standby.
                                                                                                                    • Post-transfusion: Continuous monitoring (fetus is paralyzed — change mother's position for decels). Advance to clears at 1 hour if no contractions and reassuring tracing. Earliest discharge at 2 hours if Category I tracing and fetal movements have returned.
                                                                                                                    • Twin-to-Twin Transfusion Syndrome (TTTS)
                                                                                                                      • Occurs in monochorionic pregnancies — unequal sharing of volume between donor and recipient twins.
                                                                                                                      • Fetoscopic laser ablation of placental vascular anastomoses offered for Stage 2+ (or progressing Stage 1), performed 16–26+6 weeks.
                                                                                                                      • Risks: preterm labor, PROM, membrane separation, demise of one or both fetuses, bleeding, maternal transfusion (<2%).
                                                                                                                      • Pre-op: consents in the Center, H&P, OB anesthesiology, NPO, IVF, Foley catheter prior to OR.
                                                                                                                      • Post-op: magnesium 2 g/hr (titrate up by 0.5 g/hr for >6 contractions/hr). POD 1: stop mag, remove Foley, AM CBC, regular diet, ultrasound in Center, may discharge home.
                                                                                                                      • Myelomeningocele (MMC) Closure
                                                                                                                        • Performed 24–26 weeks for isolated anomaly with normal genetics (open or fetoscopic approach).
                                                                                                                        • MOMs trial showed: less hindbrain herniation, decreased/delayed shunt placement, improved ambulation at 30 months.
                                                                                                                        • Maternal risks: preterm delivery, PROM, uterine incision complications.
                                                                                                                        • Admit night prior. Morning of: A-line placed, indomethacin at 6 AM, magnesium started, Foley placed.
                                                                                                                        • Post-op: highest risk for pulmonary edema — strict I&O, incentive spirometry is a must, continuous fetal monitoring, epidural for pain, SCDs in place. If concerns: see the patient, listen to lungs, check I&O, and CALL.
                                                                                                                        • POD 1: AM labs (CBC, CMP), continue indomethacin/heparin/SCDs/IS. Remove A-line if all agree. Mag and Foley discontinued. Transition to PO pain control (Tylenol, Dilaudid, gabapentin, Flexeril, abdominal binder).
                                                                                                                        • Fetal Arrhythmias and Transplacental Therapy
                                                                                                                          • Most common admission: fetal SVT (FHR >180 bpm for more than 10% of observation time).
                                                                                                                          • Indications for transplacental therapy: tachycardia ≥180 bpm with biphasic DV, tachycardia ≥280 bpm regardless of duration, or SVT with fetal hydrops.
                                                                                                                          • May need 24 hours of continuous monitoring to determine if transplacental therapy is needed. Risk for hydrops and fetal death.
                                                                                                                          • Most commonly treated with flecainide; additional agents include digoxin and amiodarone.
                                                                                                                          • Maternal baseline: EKG and CMP with ionized Ca, then continuous cardiac monitoring while initiating. Must have normal EKG indices (PR ≤0.2 sec, QRS ≤0.12 sec, QTc ≤0.47 sec).

                                                                                                                            • About the Speakers:

                                                                                                                            Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency.

                                                                                                                            Guest Speaker: Michelle L. Kush, MD – Assistant Professor, Maternal-Fetal Medicine, Center for Fetal Therapy in the Department of Gynecology and Obstetrics at Johns Hopkins.

                                                                                                                            Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

                                                                                                                            19 min
                                                                                                                          • Before Your First: L&D Triage Evaluation

                                                                                                                            Your first Labor & Delivery triage shift is coming up — here's how to handle it. In this episode, we walk through the full workflow: from chart-checking a patient before you walk in the room, to gathering a focused history, performing your exam, staffing efficiently, and writing a solid triage note.

                                                                                                                            Topics Covered:

                                                                                                                            • Where to Start
                                                                                                                              • Chart check the patient — age, parity, gestational age, medical and OB problems.
                                                                                                                              • Confirm dating with your own eyes. Trust but verify.
                                                                                                                              • Skim prior encounters for chronic conditions and what's worked before.
                                                                                                                              • Check if they're up to date on routine OB care (e.g., GBS swab at 36 weeks).
                                                                                                                              • Start a note using premade templates to save time.
                                                                                                                              • Bring your ultrasound, stethoscope, mask, and something to keep notes.
                                                                                                                              • If the patient is on the NST, don't wait for it to complete before performing your sono.
                                                                                                                              • Gather a focused but detailed history, then do a focused physical exam. Perform a pelvic exam as indicated (with patient consent), with or without your chief.
                                                                                                                              • Most Common Chief Complaints
                                                                                                                                • Rule out labor / preterm labor, general abdominal pain
                                                                                                                                • Rule out PPROM / SROM
                                                                                                                                • Decreased fetal movement (DFM)
                                                                                                                                • Rule out PIH / preeclampsia
                                                                                                                                • Vaginal bleeding/spotting or abnormal discharge
                                                                                                                                • Urinary symptoms, nausea/vomiting, constipation, headaches, URI symptoms
                                                                                                                                • How to Staff
                                                                                                                                  • Gather all data before staffing — evaluate the NST, review your slides, listen to lungs if needed.
                                                                                                                                  • Follow the standard SOAP format: Age, parity, GA, chief complaint → HPI → vitals, PE (including SSE/SVE) → your plan.
                                                                                                                                  • Think through: labs needed, ECG, formal sono, how long to monitor pressures, admission vs. discharge, and whether other services need to be consulted.
                                                                                                                                  • Your plan doesn't need to be 100% right — that's what intern year is for. Track patterns so you can apply them next time.
                                                                                                                                  • Closing the Loop with the Patient – Update them as things progress. If you don't know the answer, say so, then find out (UpToDate, Open Evidence, institutional resources, your chief/senior).
                                                                                                                                  • Writing Your Triage Note – Thorough but concise. Think through the differential. Update the note as labs return and the plan is finalized. Use dictation or EMR AI tools. Have your chief review notes the first few weeks.
                                                                                                                                  • After the Visit – Update the patient's problem list with any new diagnoses (e.g., pyelonephritis, gestational hypertension).

                                                                                                                                    • About the Speakers:

                                                                                                                                    Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency.

                                                                                                                                    Guest Speaker: Ore Afon, MD – Gyn/Ob resident at Johns Hopkins Hospital. She attended Cornell University for undergrad and graduated from the University of Toledo College of Medicine & Life Sciences.

                                                                                                                                    Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

                                                                                                                                    23 min
                                                                                                                                  • Before Your First: Postmenopausal Bleeding Evaluation

                                                                                                                                    Join this episode to learn about postmenopausal bleeding (PMB) — the incidence, the etiologies, and the diagnostic approach to a patient presenting with uterine bleeding after menopause. A special focus is placed on endometrial hyperplasia and endometrial malignancy, including associated risk factors and the use of transvaginal ultrasound and endometrial sampling in the evaluation. Critical evaluation of PMB is important as the leading concern is cancer until proven otherwise in this patient population.

                                                                                                                                    Keywords: Postmenopausal bleeding, Transvaginal ultrasound, Endometrial hyperplasia, Endometrial malignancy/cancer, Endometrial sampling

                                                                                                                                    Topics Covered:

                                                                                                                                    • Overview of PMB – Definition, incidence (5% of office GYN visits, 4–11% of menopausal patients), and why the leading concern is endometrial cancer until proven otherwise.
                                                                                                                                    • Etiologies
                                                                                                                                      • Polyp (~35%) – Localized overgrowths stimulated by estrogen; mostly benign but higher concern for malignancy/hyperplasia in PMB patients.
                                                                                                                                      • Atrophy (~30%) – Low estrogen leads to endometrial/vaginal atrophy, micro-erosions, and spotting.
                                                                                                                                      • Uterine Fibroid (~5%) – Less common postmenopausally; if a PMB patient has fibroids, still assume endometrial pathology.
                                                                                                                                      • Endometrial Carcinoma (6–14%) – Most common gynecologic cancer in the U.S. Type I (estrogen-driven, favorable prognosis) vs. Type II (high-grade, aggressive).
                                                                                                                                      • Endometrial Hyperplasia (with and without atypia) – May coexist with or progress to carcinoma in 30–50% of cases.
                                                                                                                                      • Other causes – Proliferative/secretory endometrium, medications (HRT, anticoagulants, tamoxifen, SSRIs), post-radiation, infection, and non-uterine sources.
                                                                                                                                      • Risk Factors for Malignancy – Increasing age, obesity, unopposed estrogen, tamoxifen, early menarche, late menopause, nulliparity, PCOS, Type 2 DM, Lynch syndrome, Cowden syndrome, and family history.
                                                                                                                                      • Diagnostic Approach
                                                                                                                                        • History and physical exam
                                                                                                                                        • Transvaginal ultrasound (TVUS) – Endometrial thickness measurement; normal <4 mm in postmenopausal women; sensitivity 94–97%.
                                                                                                                                        • Endometrial sampling – In-office EMB vs. OR-based hysteroscopy with D&C, including benefits, risks, and how to choose.
                                                                                                                                        • Follow-Up and When to Refer – Management by pathology result, when to proceed to HSC D&C, and indications for Gyn Oncology referral.

                                                                                                                                          • Resources:

                                                                                                                                          • UpToDate: Approach to the Patient with Postmenopausal Uterine Bleeding
                                                                                                                                          • ACOG Committee Opinion: The Role of Transvaginal Ultrasound in Evaluating the Endometrium of Women with Postmenopausal Bleeding
                                                                                                                                          • ACOG Clinical Consensus: Management of Endometrial Intraepithelial Neoplasia or Atypical Endometrial Hyperplasia
                                                                                                                                          • APGO Topic #54: Endometrial Hyperplasia and Carcinoma
                                                                                                                                          • ASCCP Cervical Cancer Screening Guidelines

                                                                                                                                            • About the Speakers:

                                                                                                                                            Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency.

                                                                                                                                            Guest Speaker: Emily Stock, MD – Chief resident in the Department of Gynecology & Obstetrics at Johns Hopkins Medicine. She is currently applying for GYN Oncology Fellowship.

                                                                                                                                            Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

                                                                                                                                            23 min
                                                                                                                                          • Before Your First: Benign Gyn Clinic

                                                                                                                                            Your first day in benign GYN clinic is fast-paced and can feel overwhelming. In this episode, we cover what to expect, what to review ahead of time, and practical tips for running an efficient, patient-centered clinic visit — even when you only have 15 minutes.

                                                                                                                                            Topics Covered:

                                                                                                                                            • What to Expect on Your First Day – A mix of new patients, annuals, return visits, and problem-based appointments. Common complaints include contraception, AUB, pelvic pain, abnormal discharge, STI testing, and post-op checks. Expect a fast pace and feeling slow at first.
                                                                                                                                            • What to Review Ahead of Time
                                                                                                                                              • Well woman visit guidelines
                                                                                                                                              • AUB basics (PALM-COEIN) and the initial workup
                                                                                                                                              • ASCCP guidelines (brief overview)
                                                                                                                                              • Contraceptive options and the Medical Eligibility Criteria app
                                                                                                                                              • Vaginal discharge workup — STI testing, wet prep
                                                                                                                                              • Tips for a Smooth, Efficient Clinic
                                                                                                                                                • Pre-chart! Check for recent ED visits, PCP discussions, last pap, imaging, STI results.
                                                                                                                                                • Document as you go — brief notes while talking, make them complete later.
                                                                                                                                                • Optimize your EMR — templates that make sense, favorite order sets.
                                                                                                                                                • Make eye contact.
                                                                                                                                                • Biggest Challenges and How to Overcome Them
                                                                                                                                                  • Efficiency: Practice-focused HPIs.
                                                                                                                                                  • Sensitive conversations: Sexual history, IPV screening, menses — be direct and compassionate.
                                                                                                                                                  • Pelvic exam confidence: Be trauma-informed, narrate what you're doing, be quick and confident. Don't tell patients to expect pain.
                                                                                                                                                  • Saying "I don't know": Explain your thinking, discuss with the attending, and come back.
                                                                                                                                                  • Advice We Wish We'd Known – Your confidence in pelvic exams improves dramatically. Give it time.

                                                                                                                                                    • About the Speakers:

                                                                                                                                                    Host: Lucy Brown, MD, MPH – Resident physician at Johns Hopkins GYN/OB. Dr. Brown is passionate about medical and resident education and will be pursuing a Fellowship in Complex Family Planning after residency.

                                                                                                                                                    Guest Speaker: Adrianna Gorniak, MD – Gyn/Ob resident at Johns Hopkins Hospital in Baltimore, MD. She has a passion for all things gynecology, with a special interest in complex benign gynecology.

                                                                                                                                                    Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. The views expressed are the speakers' own and do not constitute medical advice.

                                                                                                                                                    14 min

                                                                                                                                                  About Intern Ready: Ob/Gyn

                                                                                                                                                  From the publisher's feed

                                                                                                                                                  Intern Ready: Ob/Gyn is a podcast aimed at interns and off-service residents beginning their post-graduate training in Obstetrics and Gynecology. It covers critical topics for the first year of Ob/Gyn residency, including Your Intern Survival Guide—Logistics and Life, Before Your First Labor and Delivery Triage, Before Your First Benign GYN ED Consult, Before Your First Postmenopausal Bleeding Evaluation, and more.