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

When you're pregnant or breastfeeding and managing a mental health condition, the stakes feel higher than ever. One doctor tells you to stay on your medication. Another says to stop. You’re caught in the middle, scared of harming your baby but also terrified of falling apart. This isn’t just confusing-it’s dangerous. The truth is, coordinating care between your OB/GYN and psychiatrist isn’t optional. It’s the difference between a safe pregnancy and a preventable crisis.

Why Coordination Isn’t Just Helpful-It’s Essential

About 1 in 5 women experience depression or anxiety during pregnancy or after giving birth. Left untreated, these conditions raise the risk of preterm birth, low birth weight, and even long-term developmental delays in children. But switching or stopping medication without expert guidance can trigger relapse-and that’s just as risky. A 2022 study of over 8,700 pregnant women found that those with coordinated care were more than twice as likely to stay on necessary medications and had 37% fewer postpartum depressive symptoms.

The problem? Most OB/GYNs aren’t trained to manage psychiatric meds. And most psychiatrists don’t understand how pregnancy changes your body’s chemistry. That’s why you need both talking to each other-not just you repeating what each one said.

What Medications Are Safe? The Evidence-Based Shortlist

Not all antidepressants or mood stabilizers are created equal when you’re pregnant or nursing. The safest choices aren’t based on opinion-they’re backed by data from over 15,000 pregnancies tracked by the National Pregnancy Registry for Psychiatric Medications.

• Sertraline (Zoloft): First-line choice. Only a 0.5% absolute risk increase for heart defects-lower than the 1% baseline risk in the general population. It passes into breast milk in tiny amounts, and studies show no impact on infant development.
• Escitalopram (Lexapro): Nearly as safe as sertraline. Lower risk of neonatal adaptation syndrome compared to other SSRIs.
• Fluoxetine (Prozac): Avoid during late pregnancy and breastfeeding. It lingers in the body longer and can build up in babies.
• Paroxetine (Paxil): Not recommended. Linked to higher rates of heart defects. Even small doses carry more risk.
• Lithium: Used for bipolar disorder. Safe with careful monitoring. Blood levels must be checked weekly in the third trimester because your body clears it faster.
• Valproate (Depakote): Absolutely avoid during pregnancy. Raises the risk of major birth defects to over 10%.

The British Association for Psychopharmacology says: one medication, at the right dose, is better than two. Polypharmacy increases neonatal complications by 30%. Keep it simple.

The 5-Step Coordination Protocol (What Actually Works)

This isn’t theory. It’s a proven system used by top hospitals and now required by Medicaid for reimbursement.

1. Preconception planning (3-6 months before trying): Schedule a joint visit-or at least a detailed handoff. Your OB/GYN and psychiatrist should review your current meds, family history, past episodes, and whether you’ve had side effects before. This is the best time to switch to safer options if needed.
2. First-trimester check-in (by 8-10 weeks): Your body changes fast. Blood volume increases by 40-50%. Kidneys filter meds faster. Doses that worked before may not be enough now. This is when your psychiatrist adjusts your dose, not your OB/GYN guessing.
3. Monthly communication (every 4 weeks): Your OB/GYN should send a standardized note to your psychiatrist every month. It should include: medication name, dose, recent mood symptoms, sleep patterns, and any side effects. No vague messages like “she’s doing okay.” Specifics matter.
4. Third-trimester dose review: Around week 20, your liver starts processing meds faster. Sertraline’s clearance increases by 40-60%. Your psychiatrist needs to know this so they don’t let your levels drop too low.
5. Postpartum and breastfeeding plan: The first 3 weeks after birth are the highest-risk time for relapse. Your psychiatrist should be involved in the discharge plan. Breastfeeding? Sertraline and escitalopram are safest. Avoid benzodiazepines unless absolutely necessary-and even then, only for 5-7 days max.

How to Make Sure They Talk to Each Other

Here’s the hard truth: 67% of providers say their electronic records don’t talk to each other. Your OB/GYN’s system won’t notify your psychiatrist when they prescribe an antidepressant. That’s why you have to be the bridge.

• Ask your OB/GYN to send a formal referral with your diagnosis, current meds, and reason for coordination. Don’t just say “she needs help.”
• Bring a printed copy of your medication list to every appointment. Highlight the names, doses, and when you started each one.
• Use the ACOG Reproductive Safety Checklist (available online). It rates risks on a 1-10 scale for both relapse and medication exposure. Show it to both providers.
• If your psychiatrist won’t talk to your OB/GYN, ask for a warm handoff: a video call where both doctors speak together while you’re present. This is now covered by most insurance.

What to Do If They Don’t Agree

You might hear: “My OB says stop. My psychiatrist says don’t.” That’s a red flag. Neither should be making decisions alone.

• Insist on a joint consultation. You have the right to one.
• Ask for a second opinion from a maternal-fetal medicine specialist who works with psychiatrists. These are high-risk pregnancy doctors trained in mental health coordination.
• Call the National Pregnancy Registry for Psychiatric Medications (1-877-311-8972). They’ll give you free, evidence-based guidance on your specific meds.

Insurance, Costs, and Real Barriers

You might be told, “We can’t coordinate because of insurance.” That’s changing.

• Medicaid now requires documented coordination for reimbursement. If your OB/GYN won’t refer you, ask why.
• Private insurers often delay prior authorization for psychiatrists by 14+ days. Call your insurer and ask for a medical necessity review. Cite ACOG’s 2023 guidelines.
• Many hospitals now use Epic’s Perinatal Mental Health Module. It auto-notifies psychiatrists when an OB/GYN prescribes an antidepressant. Ask if your practice uses it.

What You Need to Know About Breastfeeding

Many women stop meds because they’re told breastfeeding and antidepressants don’t mix. That’s outdated.

• Sertraline and escitalopram have the lowest levels in breast milk-often less than 1% of the mother’s dose.
• Infants exposed to these meds show no difference in weight gain, sleep, or development at 6 months.
• Never stop cold turkey. Tapering under psychiatric supervision reduces withdrawal risk in the baby.
• Watch for signs of infant sedation: excessive sleepiness, poor feeding, or limpness. If you see this, call your pediatrician and psychiatrist immediately.

What Happens If You Don’t Coordinate?

A case from Project TEACH NY tells the story: A woman stopped sertraline after her OB/GYN told her it was “unsafe.” Her psychiatrist wasn’t informed. Two weeks after birth, she was hospitalized for severe postpartum depression. Her baby spent three days in the NICU due to feeding issues linked to maternal stress. She later said, “I didn’t know I had to make them talk.”

Untreated depression increases preterm birth risk by 40%. Low birth weight risk by 30%. The real danger isn’t the medication-it’s the silence between doctors.

Where to Start Today

You don’t need to fix everything tomorrow. Start here:

• Write down your current meds, doses, and when you started them.
• Call your OB/GYN and say: “I need a referral to a psychiatrist who coordinates with OB/GYNs for perinatal care.”
• Ask both providers if they use the ACOG Reproductive Safety Checklist.
• Bookmark the National Pregnancy Registry website-call them if you’re unsure.

Coordinating care isn’t about bureaucracy. It’s about keeping you alive, your baby safe, and your mind steady. You’re not asking for special treatment-you’re asking for the standard of care that’s already proven to work.

If you're reading this while pregnant or breastfeeding, you're already doing the right thing by seeking answers. Now take one step: call your OB/GYN and ask if they coordinate with a psychiatrist. If they don’t, ask why-and insist they start.