How to Coordinate Care Between OB/GYN and Psychiatrist for Medications During Pregnancy and Breastfeeding

When you're pregnant or breastfeeding and need psychiatric medication, you're not just managing your mental health-you're managing two lives. That’s why coordinating care between your OB/GYN and psychiatrist isn’t just helpful-it’s essential. Too often, women get caught in the middle: their OB/GYN says one thing about medication safety, their psychiatrist says another, and no one talks to each other. The result? Unnecessary stress, medication changes that don’t make sense, or worse-stopping treatment altogether when it’s needed most.

Why Coordination Isn’t Optional

About 1 in 5 women experience depression, anxiety, or bipolar disorder during pregnancy or after giving birth. Left untreated, these conditions raise the risk of preterm birth, low birth weight, and even postpartum suicide. But the same medications that help you feel like yourself again can raise questions about safety for your baby. That’s where coordination kicks in.

The American College of Obstetricians and Gynecologists (ACOG) made it clear in 2023: treating mental illness during pregnancy isn’t a choice between two risks-it’s about balancing both. The biggest danger? Not taking medication when it’s needed. Untreated severe depression increases the chance of preterm birth by 40% and low birth weight by 30%. The goal isn’t to avoid all medication-it’s to use the right one, at the right dose, at the right time.

Which Medications Are Safest?

Not all antidepressants are created equal when you’re pregnant or breastfeeding. Research shows some have far better safety records than others.

• Sertraline is the top choice. It crosses the placenta minimally, has very low levels in breast milk, and shows no significant increase in birth defects. Studies tracking over 15,000 pregnancies found only a 0.5% absolute risk increase for heart defects-barely higher than the 1% baseline risk in the general population.
• Escitalopram is a close second. It’s also well-studied, with minimal transfer to the baby and low risk of neonatal withdrawal symptoms.
• Paroxetine is not recommended. Even though it works for some, it’s linked to a slightly higher risk of heart defects and should be avoided if possible.
• Mood stabilizers like lithium can be used in bipolar disorder, but require close monitoring. Valproate, however, is a hard no-it carries a 10.7% risk of major birth defects.

The British Association for Psychopharmacology (BAP) adds another key point: use one medication at a time. Mixing drugs increases the chance of side effects for your baby. Single-agent therapy cuts neonatal complications by 30% compared to multiple prescriptions.

How the Coordination Process Actually Works

This isn’t just about sending a referral. Effective coordination follows a clear, step-by-step structure.

1. Preconception planning-If you’re trying to get pregnant, meet with both providers at least 3 to 6 months ahead. This is the best time to adjust meds, switch to safer options, or stabilize your dose before conception.
2. First joint check-in by 8-10 weeks-That’s when your baby’s organs are forming. Both providers should review your current meds, dosages, and mental health history together.
3. Regular updates every 4 weeks-Pregnancy changes how your body processes drugs. Blood volume increases by 40-50%, and your liver metabolizes meds faster, especially in the third trimester. Doses may need adjusting.
4. Use a shared checklist-ACOG’s Reproductive Safety Checklist rates risks on a 1-10 scale for both relapse and medication exposure. It turns abstract fears into concrete numbers: “Without treatment, your chance of relapse is 65%. With sertraline, your baby’s risk of heart defect is 0.5%.”
5. Document everything in both records-If your OB/GYN and psychiatrist use different electronic systems, ask for printed summaries. Many providers still report communication gaps because their systems don’t talk to each other.

What Happens After Baby Is Born?

Breastfeeding doesn’t mean you have to stop your meds. Most SSRIs, especially sertraline, appear in breast milk at trace levels-often lower than what the baby was exposed to in the womb.

The National Pregnancy Registry for Psychiatric Medications tracks outcomes from over 15,000 pregnancies and breastfeeding cases. Their 2023 data shows no increased risk of developmental delays or behavioral issues in babies exposed to sertraline or escitalopram through breast milk.

But here’s the catch: your body changes after birth. Hormones drop fast. Your medication needs may shift again. Many women feel fine during pregnancy, then crash after delivery. That’s why follow-ups at 2, 6, and 12 weeks postpartum are critical. Your psychiatrist should be involved in adjusting your dose-not your OB/GYN alone.

Common Barriers and How to Get Around Them

Even with solid guidelines, real-world coordination still falls short.

• Insurance delays-57% of privately insured women wait more than 14 days for prior authorization to see a psychiatrist. Call your insurer early. Ask your OB/GYN to write a letter of medical necessity. Many practices now have care coordinators who handle this for you.
• Electronic health record (EHR) gaps-67% of providers say their systems don’t share data. If your OB/GYN uses Epic and your psychiatrist uses Cerner, ask for a printed summary to hand-deliver or fax.
• Conflicting advice-On Reddit’s r/PPD community, 68% of users reported getting mixed messages. One woman stopped sertraline after her OB/GYN said it was “risky,” then developed severe postpartum depression. She ended up hospitalized. Don’t let conflicting advice stop you. Ask both providers to explain their reasoning. If they can’t agree, request a joint appointment.

When to Push for a Joint Appointment

You don’t have to wait for your providers to suggest it. If you’re on mood stabilizers, have a history of bipolar disorder, or are struggling with treatment-resistant depression, insist on a shared visit. Kaiser Permanente’s integrated model shows 89% patient satisfaction when both specialists meet together-either in person or via video.

During these meetings, ask:

• “What’s the risk of relapse if I stop this medication?”
• “What’s the actual risk to my baby, not just ‘it might be risky’?”
• “Can we use the Reproductive Safety Checklist to score this together?”
• “Will you both update each other’s records after this visit?”

The Future Is Getting Better

Change is happening. In January 2024, the FDA updated prescribing labels for psychiatric meds to include direct recommendations for OB/GYN coordination. Sertraline’s label now says: “Coordination with obstetric provider recommended for dose adjustment beginning at 20 weeks due to increased clearance.”

Hospitals are catching up too. Epic Systems launched its Perinatal Mental Health Module in early 2023. When an OB/GYN prescribes an antidepressant, the system automatically alerts the patient’s psychiatrist. Over 1,200 U.S. hospitals now use it.

The NIH is launching a major study in late 2024 called PACT, tracking 5,000 pregnancies with genetic testing to predict which meds work best for each woman. This isn’t sci-fi-it’s the next step toward truly personalized care.

What You Can Do Today

You don’t need to wait for the system to fix itself. Here’s your action plan:

1. If you’re pregnant or planning to be, ask your OB/GYN: “Do you work with a psychiatrist for medication management?”
2. If they say no, ask for a referral to a maternal mental health specialist.
3. Bring a printed list of your current meds, dosages, and mental health history to your next appointment.
4. Request a joint consultation if you’re on mood stabilizers, have a history of psychosis, or your symptoms are worsening.
5. Use ACOG’s Reproductive Safety Checklist to track risks side-by-side.
6. Keep a simple log: date, mood score (1-10), meds taken, any side effects.

Final Thought: Your Mental Health Is Part of Your Pregnancy Care

Pregnancy isn’t just about ultrasounds and prenatal vitamins. It’s about the whole person-the mind included. Treating depression or anxiety isn’t overmedicating. It’s protecting your ability to bond with your baby, to sleep, to eat, to get through the day. The best care doesn’t choose between you and your baby. It chooses both.