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

When a woman is pregnant or breastfeeding and needs psychiatric medication, she doesn’t just need a prescription-she needs a team. Too often, women are caught between two systems: their OB/GYN, focused on the baby’s safety, and their psychiatrist, focused on their mental health. Neither has the full picture. The result? Confusing advice, medication changes that don’t make sense, or worse-stopping treatment out of fear. But there’s a better way. Coordinated care between OB/GYNs and psychiatrists isn’t optional anymore. It’s the standard of care for perinatal mental health, backed by evidence, guidelines, and real-world outcomes.

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 developmental delays in children. But the medications that help-like SSRIs-can feel scary. Sertraline and escitalopram are the safest options, with only a 0.5% absolute increase in cardiac defects compared to the 1% baseline risk in the general population. That’s lower than the risk from being overweight or smoking during pregnancy. Yet, 42% of women stop their meds because they’re told to, without a full risk-benefit discussion.

The truth is, the most dangerous medication during pregnancy is no medication when it’s needed. Untreated depression increases the chance of preterm birth by 40% and low birth weight by 30%. Coordinating care means weighing these real risks against the small, measurable risks of medication. And that’s not something an OB/GYN can do alone-nor should a psychiatrist decide without understanding how pregnancy changes how the body processes drugs.

How Pregnancy Changes Medication in Your Body

Pregnancy isn’t just about growing a baby-it’s about your whole body changing how it handles medicine. Blood volume goes up by 40-50%. Your kidneys filter faster. Liver enzymes that break down drugs become more active, especially in the third trimester. That means many medications clear out of your system faster. A dose that worked before pregnancy might not be enough by week 30.

For example, sertraline’s clearance increases by 40-60% in late pregnancy. Without a dose adjustment, you could slip into depression again. That’s why the FDA updated sertraline’s prescribing label in January 2024 to specifically recommend coordination with your OB/GYN for dose changes starting at 20 weeks. Other medications, like lamotrigine for bipolar disorder, need even more careful monitoring. Its levels can drop by 50-70% during pregnancy, requiring frequent blood tests and adjustments.

This is why a psychiatrist who doesn’t understand pregnancy pharmacokinetics could give bad advice. And an OB/GYN who doesn’t know how to interpret psychiatric medication data could miss signs of relapse. Coordination bridges that gap.

The 5-Step Coordination Protocol

The American College of Obstetricians and Gynecologists (ACOG) laid out a clear, step-by-step plan for how this should work. It’s not complicated-it just needs to be followed.

1. Preconception Planning - If you’re trying to get pregnant, meet with both providers at least 3-6 months before conception. Review your current meds. Discuss alternatives. Make a plan. This is the best time to switch from a riskier drug like paroxetine (linked to heart defects) to sertraline or escitalopram.
2. First Coordination Meeting - By 8-10 weeks pregnant, both providers should connect. Share your history, current symptoms, and medication list. Use ACOG’s Reproductive Safety Checklist to score risks on a 1-10 scale for both relapse and medication exposure.
3. Regular Check-Ins - Every 4 weeks for stable cases. Weekly if you’re adjusting doses or having symptoms. Communication isn’t just a note in the chart-it’s a conversation. Shared templates with 12 key data points (protein binding, placental transfer, lactation risk) make this efficient.
4. Medication Review at 20 Weeks - This is when many drugs need dose increases. Your OB/GYN should alert the psychiatrist. The psychiatrist should confirm the new dose is safe and effective. No guesswork.
5. Postpartum and Breastfeeding Plan - Medication needs change again after birth. Your body clears drugs faster during pregnancy, but after delivery, metabolism slows. A dose that was perfect at 38 weeks might cause drowsiness or withdrawal in your baby after birth. Breastfeeding adds another layer: sertraline has the lowest transfer into breast milk of any SSRI. Most guidelines say it’s safe. But only if both providers agree on the plan.

What Medications Are Safe? The Real Data

Not all antidepressants are created equal. Here’s what the data says:

• Sertraline - First-line choice. Lowest transfer into breast milk. 0.5% absolute risk increase in cardiac defects. No link to autism or developmental delays in long-term studies.
• Escitalopram - Almost as safe as sertraline. Slightly less data on breastfeeding, but still considered low risk.
• Fluoxetine - Longer half-life. Can build up in the baby. Avoid in late pregnancy unless necessary.
• Paroxetine - Avoid. Linked to heart defects. Even small doses carry risk.
• Mood stabilizers - Lithium and valproate are high risk. Valproate causes major birth defects in over 10% of cases. Lithium requires close monitoring of kidney and thyroid function. Lamotrigine is safer but needs dose adjustments.
• Benzodiazepines - Avoid unless absolutely necessary. Even short-term use can cause withdrawal in newborns. If used, limit to 5-7 days with psychiatrist oversight.

The National Pregnancy Registry for Psychiatric Medications tracks over 15,000 pregnancies. Their 2023 data confirms: no major increase in birth defects with sertraline, escitalopram, or fluvoxamine. Paroxetine remains the only SSRI with a clear signal of risk.

Barriers-And How to Overcome Them

Even with clear guidelines, coordination doesn’t always happen. Why?

• Electronic Health Records Don’t Talk - 67% of providers say their OB/GYN and psychiatric systems can’t share data. Solution: Use secure messaging platforms like Epic’s Perinatal Mental Health Module, now used by 1,247 U.S. healthcare systems. If your provider doesn’t use it, ask them to start.
• Insurance Delays - 57% of privately insured women wait over 14 days for prior authorization for psychiatric care. Solution: Ask your OB/GYN to write a letter of medical necessity. Many insurers approve faster when the OB/GYN initiates the request.
• Conflicting Advice - On Reddit’s r/PPD community, 68% of women reported getting contradictory advice. One woman stopped sertraline after her OB/GYN said it was unsafe, then had a severe postpartum depression episode requiring hospitalization. Solution: Demand a joint visit. Both providers in the same room. No phone calls. No emails. One conversation.
• Time Constraints - OB/GYNs are busy. Psychiatrists are overbooked. Solution: Use telehealth. ACOG now accepts asynchronous consultations completed within 72 hours for stable patients. A 15-minute video call can replace a week of back-and-forth messages.

What Good Coordination Looks Like

Kaiser Permanente’s integrated model shows what’s possible. Patients get a joint visit with their OB/GYN and psychiatrist at 10 weeks. Both providers document in the same chart. Medication changes are approved by both. Patients report 89% satisfaction-compared to 63% in non-integrated care.

The key? Shared decision-making. Not just telling you what’s safe-but showing you the numbers. A good provider will say: “Without treatment, you have a 65% chance of relapse. With sertraline, your baby’s risk of a heart defect is 0.5%. That’s less than the risk of being over 35 years old when pregnant.”

They’ll also have a plan for breastfeeding. Most SSRIs are safe. Sertraline is the gold standard. But you need to know how to watch for side effects in your baby: excessive sleepiness, poor feeding, or jitteriness. Your psychiatrist should teach you that. Your OB/GYN should follow up on it.

What to Ask Your Providers

Don’t wait for them to lead. Ask these questions:

• “Which medication are you recommending, and why?”
• “What’s the risk of relapse if I stop?”
• “What’s the risk to my baby if I take it?”
• “Will you communicate with my other provider? Can we have a joint visit?”
• “Are you using ACOG’s Reproductive Safety Checklist?”
• “Will my dose change during pregnancy? When?”
• “Is this safe for breastfeeding? What signs should I watch for in my baby?”

If they can’t answer these clearly, ask for a referral to a provider who can. There are specialists in perinatal psychiatry. They exist. You just have to ask.

What’s Changing in 2025

The field is moving fast. In 2024, the NIH launched the PACT trial, tracking 5,000 pregnancies with genetic testing to personalize medication choices. By 2025, ACOG plans to roll out AI tools that predict your risk of relapse based on your history, genetics, and medication response. These tools are already 89% accurate in early testing.

Medicare and Medicaid now require documented coordination for reimbursement. Hospitals are being scored on it. That means more practices are finally adopting these protocols-not because they want to, but because they have to.

The bottom line? You don’t have to choose between being mentally well and having a healthy baby. You just need two providers who talk to each other. And you have the right to make sure they do.

Next Steps

If you’re pregnant or planning to be, and you’re on psychiatric medication:

• Ask your OB/GYN if they coordinate with a psychiatrist.
• Ask your psychiatrist if they have experience with perinatal patients.
• Request a joint visit-no excuses.
• Use ACOG’s Reproductive Safety Checklist to track risks.
• Keep a log of your symptoms and medication side effects.
• Don’t stop or change meds without both providers’ input.

Your mental health is part of your reproductive health. You don’t have to choose between them. You just need the right team-and the courage to ask for it.