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 OB/GYN and psychiatrist coordination isn’t optional. It’s essential. Too many women are caught in the middle: their OB/GYN says to stop their antidepressant, their psychiatrist says to stay on it, and no one talks to each other. The result? Unnecessary anxiety, relapse, or worse-hospitalization after delivery. The good news? There’s a clear, evidence-backed way to make this work.

Why Coordination Matters More Than You Think

One in five women will experience depression or anxiety during pregnancy or after birth. Left untreated, it raises the risk of preterm birth by 40%, low birth weight by 30%, and even long-term developmental delays in the child. But starting or stopping psychiatric meds on your own? That’s risky too. Some medications cross the placenta. Some show up in breast milk. The key isn’t avoiding meds-it’s choosing the right one, at the right dose, at the right time.

A 2022 JAMA Psychiatry study of over 8,700 pregnant women found that those who had coordinated care between their OB/GYN and psychiatrist were 57% less likely to stop their medication early. Their postpartum depression rates dropped by 37%. That’s not a small win. That’s life-changing.

What Medications Are Safe? The Real Data

Not all antidepressants are created equal during pregnancy. Sertraline and escitalopram are the two most studied and safest options. Sertraline has a 0.5% absolute risk increase for heart defects-compared to a 1% baseline risk in the general population. That’s lower than the risk from a common cold during pregnancy. Paroxetine, on the other hand, carries a higher risk and is no longer recommended as a first choice.

For bipolar disorder, lithium and lamotrigine are often used, but valproate is a hard no-it increases the chance of major birth defects to over 10%. Mood stabilizers aren’t always stopped during pregnancy. In fact, stopping them can be more dangerous than keeping them. Relapse rates for bipolar disorder during pregnancy hit 70% if meds are discontinued.

The British Association for Psychopharmacology recommends monotherapy over combinations. Using one medication at an optimized dose reduces neonatal complications by 30% compared to stacking two or more drugs. Simpler is safer.

How the Coordination Process Actually Works

There’s a proven 5-step process backed by the American College of Obstetricians and Gynecologists (ACOG) and used in top hospitals like Kaiser Permanente and Massachusetts General.

1. Preconception planning-If you’re trying to get pregnant, meet with both providers at least 3 to 6 months ahead. Review your current meds, adjust doses if needed, and get baseline labs. This isn’t optional-it’s the best time to make changes.
2. First joint check-in by 8-10 weeks-This is when the placenta is fully formed. Both providers should review your medication, dosage, and mental health history. Use a shared checklist like ACOG’s Reproductive Safety Tool, which rates risks on a 1-10 scale for both relapse and fetal exposure.
3. Regular communication every 4 weeks-For stable patients. Weekly if you’re struggling. Use standardized forms that include protein binding levels, placental transfer rates, and lactation risk categories. These aren’t jargon-they’re real numbers that guide decisions.
4. Medication adjustments during third trimester-Your body changes. Blood volume increases by 40-50%. Kidneys filter faster. This means many meds clear out quicker. Sertraline’s clearance increases by up to 60% in the third trimester. Your dose may need to go up. Don’t wait until you feel worse-adjust early.
5. Postpartum transition plan-Your body resets fast after birth. Hormones crash. Sleep vanishes. Medication needs change again. Your psychiatrist should be involved in the first week postpartum, not the sixth. Delayed follow-up is a leading cause of postpartum hospitalizations.

Barriers You’ll Likely Face (And How to Beat Them)

This system works-but it’s not easy. Here’s what gets in the way:

• Electronic health records don’t talk-67% of providers say their OB/GYN and psychiatrist use different systems. No shared notes. No alerts. Solution: Ask for a printed care summary to hand-deliver between appointments.
• Insurance delays-57% of privately insured women wait over 14 days for prior authorization to see a psychiatrist. If you’re in crisis, call your OB/GYN’s office and ask them to call the insurer on your behalf. Many have care coordinators who can push through these delays.
• Conflicting advice-On Reddit’s r/PPD community, 42% of women reported getting opposite advice from their two providers. One says “stop,” the other says “don’t.” Document everything. Bring both providers’ recommendations to a third opinion if needed. ACOG’s guidelines are your backup.
• Benzodiazepines-These are sometimes used for severe anxiety. But they’re risky in pregnancy. If you need them, it should be for less than two weeks, with weekly check-ins from your psychiatrist. No long-term use.

What to Ask Your Providers

Don’t wait for them to lead. Be the one who asks the right questions:

• “Is this medication on ACOG’s recommended list for pregnancy?”
• “What’s the placental transfer rate for this drug?”
• “Will my dose need to change in the third trimester?”
• “Can we schedule a joint visit-either in person or via video?”
• “Will you communicate directly with my other provider, or should I bring a summary?”
• “What’s the plan if I relapse after delivery?”

What About Breastfeeding?

Many women panic about breastfeeding while on meds. The truth? Most SSRIs are safe. Sertraline and escitalopram have the lowest levels in breast milk. The American Academy of Pediatrics says they’re compatible with breastfeeding. Babies exposed to these meds in breast milk show no increased risk of developmental delays.

The real danger? Stopping your medication because you’re afraid of breastfeeding. That’s what leads to severe postpartum depression-and that’s what harms the baby more than any trace of medication.

If you’re on lithium or valproate, talk to your psychiatrist. Those require closer monitoring. But for most antidepressants, breastfeeding is not only safe-it’s encouraged.

The Bigger Picture: Why This System Is Changing

The $4.2 billion perinatal mental health market is growing fast. Medicaid programs now require documented coordination between OB/GYNs and psychiatrists for reimbursement. CMS gives practices a 5% bonus if they show communication in 90% of perinatal cases. Epic’s Perinatal Mental Health Module, used by over 1,200 hospitals, now auto-notifies psychiatrists when an OB/GYN prescribes an antidepressant.

The future? AI-driven risk models are being tested to predict which women will need dose adjustments based on genetics and metabolism. A NIH-funded trial called PACT, launching in late 2024, will track 5,000 pregnancies using genetic testing to match meds to individuals.

This isn’t science fiction. It’s happening now.

What to Do Right Now

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

• Ask your OB/GYN if they’ve coordinated care with a psychiatrist for other patients.
• If they haven’t, ask them to call one. Many have referral lists.
• Bring a printed list of your meds, doses, and side effects to both appointments.
• Request a shared care plan in writing.
• Don’t stop or change your meds without both providers agreeing.

You’re not being difficult for asking for coordination. You’re being smart. And in a system that too often silos care, that’s the most powerful thing you can do.