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. The stakes are high. Untreated depression or anxiety can lead to preterm birth, low birth weight, or even postpartum psychosis. But some medications carry risks too. That’s why coordinating care between your OB/GYN and psychiatrist isn’t optional-it’s essential.

Why You Can’t Rely on One Doctor Alone

Your OB/GYN knows your body through pregnancy: how your blood volume increases by 40-50%, how your kidneys filter faster, how your liver processes drugs differently in each trimester. Your psychiatrist knows your brain: which meds work for your diagnosis, how to adjust doses for side effects, when to switch if things go wrong.

But most OB/GYNs aren’t trained to fine-tune antidepressants. Most psychiatrists don’t track how pregnancy changes drug metabolism. Left to one provider, you’re at risk. A 2022 JAMA Psychiatry study of over 8,700 pregnant women found that when care wasn’t coordinated, 42% stopped their meds-often because they were scared, confused, or got conflicting advice. Those who stopped were 37% more likely to have severe postpartum depression.

The fix? You need both doctors talking-regularly, clearly, and with the same data.

What Medications Are Safe? The Evidence-Based Shortlist

Not all antidepressants are created equal during pregnancy. The American College of Obstetricians and Gynecologists (ACOG) gives clear guidance based on 147 studies:

• Sertraline is the top choice. It crosses the placenta minimally, has a half-life of 26 hours (perfect for steady levels), and shows only a 0.5% absolute increase in heart defects-compared to the 1% baseline risk in the general population.
• Escitalopram is a close second. It’s well-studied, has fewer drug interactions, and is preferred if you’ve had side effects with sertraline.
• Paroxetine is not recommended. It’s linked to a higher risk of heart defects and should be avoided if possible.

For bipolar disorder, lithium and lamotrigine are often used, but valproate is a hard no-it raises the risk of major birth defects to nearly 11%, compared to 2-3% normally.

The British Association for Psychopharmacology adds another key rule: one medication, at the right dose, is better than two. Using just one drug cuts neonatal complications by 30% compared to mixing pills.

The 5-Step Coordination Protocol

This isn’t guesswork. There’s a proven system, backed by ACOG and used in top hospitals like Kaiser Permanente:

1. Preconception planning (ideal: 3-6 months before trying to conceive). Meet with both doctors together. Review your current meds. Discuss risks vs. benefits. Update your medication plan. Document it in both records.
2. First coordination meeting by 8-10 weeks pregnant. This is when the placenta starts forming. Your OB/GYN should check your medication levels. Your psychiatrist should adjust dose if needed-because pregnancy increases how fast your body clears drugs by up to 60% in the third trimester.
3. Regular check-ins every 4 weeks. Stable? Monthly. Struggling? Weekly. Use a shared template: protein binding, placental transfer rate, lactation risk, maternal relapse risk, and fetal safety score. ACOG’s Reproductive Safety Checklist turns abstract fears into numbers-like “65% chance of relapse without meds, 0.5% risk of heart defect with sertraline.”
4. Postpartum transition plan. Your body changes fast after birth. Hormones crash. Sleep disappears. Medication needs change again. Your psychiatrist should adjust doses before you leave the hospital. Your OB/GYN should screen for mood shifts at your 2-week checkup.
5. Breastfeeding safety check. Sertraline and escitalopram are the safest for nursing. Less than 1% of the dose passes into breast milk. Other meds? Avoid them unless absolutely necessary. If you’re on lithium or valproate, your baby’s blood levels need monitoring.

What Gets Lost in Translation

Even with good guidelines, things fall apart. A 2021 study found 67% of OB/GYNs and psychiatrists use different electronic health records. One doctor writes “sertraline 50mg,” the other sees “Zoloft 50mg.” One doesn’t know the other adjusted the dose last week.

Patients report this too. On Reddit’s r/PPD, 68% of 1,247 respondents said they got conflicting advice. One woman in New York stopped her sertraline after her OB/GYN said it was “too risky.” Her psychiatrist had said it was safe. She developed severe postpartum depression and ended up hospitalized.

The fix? Shared documentation. Use a printed or digital form that both providers sign off on. Include:

• Current meds and doses
• Reason for each medication
• Planned adjustments for pregnancy/breastfeeding
• Red flags: when to call either doctor immediately

Insurance, Access, and Real-World Barriers

You might have the right plan-but still hit walls. Private insurance often delays psychiatric referrals by 14+ days due to prior authorization. Medicaid programs now require coordinated care for reimbursement, but not all OB/GYNs know how to trigger it.

In private practices, only 32% of providers use formal coordination. In academic hospitals? 78%. If you’re in a smaller clinic, you may need to push.

Ask your OB/GYN: “Can you send a consult request to a psychiatrist who works with your team?” If they say no, ask for a referral to a maternal mental health program. Many hospitals now have them. Kaiser Permanente’s integrated model has 89% patient satisfaction-because the two doctors sit in the same building and see you together.

What About Benzodiazepines?

If you’re on Xanax or Klonopin for anxiety, this is urgent. ACOG strongly recommends avoiding them during pregnancy. They’re linked to cleft palate and withdrawal symptoms in newborns.

But 31% of women with severe anxiety still need them short-term. The solution? A time-limited prescription-no more than 2 weeks-with weekly check-ins from your psychiatrist. Your OB/GYN should track fetal movement and growth more closely during this time.

What’s Changing in 2025?

The rules are evolving fast. In January 2024, the FDA updated sertraline’s label to say: “Coordination with obstetric provider recommended for dose adjustment beginning at 20 weeks gestation due to increased clearance.” That’s new. That’s important.

By late 2024, a major NIH study called PACT will start tracking 5,000 pregnancies using genetic testing to predict which antidepressant works best for each woman. AI models are already being tested to predict relapse risk with 89% accuracy.

And CMS-the agency that pays Medicare and Medicaid-is now giving practices a 5% bonus if they document coordinated care in 90% of perinatal cases. That’s pushing hospitals to finally fix broken systems.

Your Action Plan

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

• Ask your OB/GYN: “Do you work with a psychiatrist who specializes in perinatal care?”
• If they don’t, ask for a referral to a maternal mental health clinic or a hospital with a perinatal psychiatry program.
• Bring a printed list of your meds, doses, and concerns to your next appointment.
• Request a joint visit-phone or video-if in-person isn’t possible.
• Use the ACOG Reproductive Safety Checklist to track your own risk scores.
• Never stop your meds without talking to both doctors.

What If You Can’t Get Coordination?

You’re not alone. Many women struggle to get both specialists on the same page. If you’re stuck:

• Call the National Pregnancy Registry for Psychiatric Medications. They’ll connect you with a specialist and help track your outcomes.
• Use the PSYCHIATRIC MEDICATION SAFETY TOOL from WomensMentalHealth.org-it’s free, simple, and gives you clear risk summaries.
• Write down your questions and bring them to every appointment. You’re the only one who sees both worlds. You’re the most important person in this care team.

The truth? The safest medication during pregnancy isn’t always the one with the lowest risk. It’s the one that keeps you stable. Untreated depression carries a 40% risk of preterm birth. A 30% higher chance of low birth weight. Your mental health isn’t separate from your pregnancy-it’s part of it.

Coordinating care isn’t about bureaucracy. It’s about making sure you get the right help, at the right time, without having to choose between being well and being safe.