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 many women get caught in the middle: one provider says to stay on sertraline, another says to stop. One gives you a risk chart, another says, ‘It’s probably fine.’ This confusion leads to unnecessary medication stops, worsening depression, and even hospitalizations. But there’s a better way.

Why Coordination Isn’t Optional

About 1 in 5 women experience depression or anxiety during pregnancy or after birth. Left untreated, that increases the risk of preterm birth by 40%, low birth weight by 30%, and even difficulties bonding with your baby. But some medications carry small risks too. Sertraline, for example, has a 0.5% absolute risk increase for heart defects-compared to a 1% baseline risk in the general population. That’s why you need both specialists talking to each other. Your OB/GYN knows how pregnancy changes your body-your blood volume goes up by 40-50%, your liver processes drugs faster, and your kidneys filter more. Your psychiatrist knows how those changes affect your medication levels. Without them working together, you’re flying blind.

What Medications Are Safe? The Evidence

Not all antidepressants are created equal during pregnancy. The American College of Obstetricians and Gynecologists (ACOG) recommends sertraline and escitalopram as first-line choices. Why? They cross the placenta less than others, have fewer active metabolites, and are backed by data from over 15,000 pregnancies tracked by the National Pregnancy Registry for Psychiatric Medications. Paroxetine, on the other hand, is linked to a higher risk of heart defects and is no longer recommended as a first option.

For bipolar disorder, mood stabilizers like lithium and lamotrigine are often continued-but valproate is strongly avoided. It raises the risk of major birth defects to nearly 11%, compared to 2-3% in the general population. If you’re on a benzodiazepine for anxiety, ACOG advises against long-term use. Short-term, low-dose use under weekly psychiatrist supervision is acceptable if absolutely needed.

During breastfeeding, most SSRIs are considered safe. Sertraline is the top pick again-only tiny amounts pass into breast milk, and studies show no developmental delays in infants. Fluoxetine? Not so much. It sticks around longer in the baby’s system. Always check the LactMed database, maintained by the NIH, for updated safety ratings.

When and How to Start Coordination

Don’t wait until you’re 20 weeks pregnant and feeling overwhelmed. The best time to start is before conception. If you’re planning a pregnancy, schedule a joint consultation with both your OB/GYN and psychiatrist. They’ll review your current meds, adjust doses if needed, and set up a monitoring plan. This isn’t just a one-time meeting-it’s the foundation.

If you’re already pregnant, aim for your first coordinated visit by 8-10 weeks. After that, communication should happen at least every four weeks if things are stable. If you’re having a flare-up or your dose is being changed, weekly check-ins are standard. Most successful practices use standardized templates that include:

• Current medication, dose, and timing
• Protein binding percentage (sertraline is 98%)
• Placental transfer rate
• Lactation risk category (L1-L5)
• Maternal relapse risk if discontinued
• Infant exposure estimate

This isn’t paperwork for the sake of it. It’s a shared decision-making tool. One patient told her team: ‘I didn’t know the risk of stopping my meds was higher than the risk of staying on them. Seeing it on paper changed everything.’

What Gets in the Way?

The biggest barrier? Broken systems. A 2021 study found 67% of OB/GYNs and psychiatrists use different electronic health records that don’t talk to each other. That means someone has to fax records, call between appointments, or hope the patient remembers to bring up a change. It’s inefficient-and dangerous.

Insurance is another hurdle. In the UK and US, prior authorizations for psychiatric visits can take over two weeks. That’s a lifetime in perinatal mental health. If you’re waiting for approval and your symptoms are worsening, tell your OB/GYN. They can often prescribe a short-term bridge or escalate the request.

Some providers still think, ‘I’m not a psychiatrist-I shouldn’t prescribe this.’ But ACOG’s guidelines say otherwise. OB/GYNs are trained and encouraged to initiate treatment for mild to moderate depression and anxiety. You don’t need to wait for a psychiatrist to see you first. The goal is collaboration, not gatekeeping.

What Works in Real Life

Kaiser Permanente’s integrated model shows what’s possible. Their teams hold joint virtual visits where both providers are on the call. Patients get a printed Reproductive Safety Checklist-rated 1 to 10 for both relapse risk and medication risk. One woman, 32, pregnant with her second child, had stopped her antidepressant after a bad experience with her first pregnancy. She was anxious, sleeping poorly, and crying daily. Her OB/GYN referred her to a psychiatrist who was part of the same system. Within two weeks, they restarted sertraline at 50mg, monitored her levels, and adjusted based on her symptoms and trimester. She delivered a healthy baby and breastfed for 10 months without relapse.

On Reddit’s r/PPD community, 68% of users reported conflicting advice. One woman was told by her OB/GYN to stop all meds. Her psychiatrist said she’d likely relapse. She chose to stop. Three weeks after birth, she was hospitalized for severe postpartum psychosis. That’s not an outlier. That’s what happens when coordination fails.

What’s New in 2025?

The landscape is changing fast. In early 2024, the FDA updated medication labels to include specific coordination recommendations. Sertraline’s label now says: ‘Coordination with obstetric provider recommended for dose adjustment beginning at 20 weeks gestation due to increased clearance.’ That’s huge. It means prescribing info now reflects real-world clinical practice.

New tools are rolling out too. Epic Systems’ Perinatal Mental Health Module, used by over 1,200 U.S. hospitals, now automatically alerts psychiatrists when an OB/GYN prescribes an antidepressant. In the UK, NHS Digital is piloting similar systems. AI-driven risk models are being tested in research trials-predicting which women are most likely to relapse based on genetics, past episodes, and stress levels. These aren’t sci-fi. They’re coming to your clinic.

Your Next Steps

If you’re pregnant or planning to be, here’s what to do:

1. Ask your OB/GYN if they work with a perinatal psychiatrist. If not, ask for a referral.
2. Request a joint appointment-or at least a written care plan signed by both providers.
3. Bring your current medication list and any past mental health records.
4. Ask: ‘What’s the risk of stopping this? What’s the risk of keeping it?’ Get numbers.
5. Use the National Pregnancy Registry (www.pregnancyregistry.org) to enroll if you’re on medication-it helps future moms.
6. If you’re breastfeeding, check LactMed or ask your pharmacist for the latest safety rating.

You don’t have to choose between being a good mom and being mentally well. The science is clear: treating your mental health protects your baby too. But only if your providers are on the same page.