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 coordination between your OB/GYN and psychiatrist isn’t optional. It’s essential. Too often, women are caught between providers who don’t talk to each other, leading to dangerous gaps in care. One doctor says to stay on sertraline; another says to stop. You’re left confused, scared, and sometimes, off your meds entirely. The result? Higher risk of relapse, preterm birth, low birth weight, or even hospitalization. But it doesn’t have to be this way.

Why Coordination Matters More Than Ever

One in five women experiences depression or anxiety during pregnancy or after giving birth. Left untreated, these conditions raise the risk of preterm birth by 40% and low birth weight by 30%. But the fear of medication harming the baby often leads women to stop treatment-sometimes abruptly. That’s when things get dangerous. Untreated depression carries more risk than most psychiatric medications do during pregnancy.

The American College of Obstetricians and Gynecologists (ACOG) made this clear in 2023: coordinated care reduces medication discontinuation rates from 42% to just 18%. When OB/GYNs and psychiatrists work together, postpartum depression symptoms drop by 37%. That’s not a small win. That’s life-changing.

Yet, 67% of providers say their electronic records don’t talk to each other. A woman might see her OB/GYN in Halifax, get prescribed sertraline, then visit her psychiatrist in Dartmouth-and neither provider knows what the other prescribed. That’s not care. That’s chaos.

Which Medications Are Safe? The Evidence-Based List

Not all psychiatric meds are created equal during pregnancy and breastfeeding. Some cross the placenta easily. Others are barely detectable in breast milk. Here’s what the latest data shows:

• Sertraline (Zoloft): First-line choice. Only 0.5% absolute increase in cardiac defects compared to the 1% baseline risk. Less than 1% of the maternal dose passes into breast milk. Highest safety rating for breastfeeding.
• Escitalopram (Lexapro): Similar safety profile. Lower risk of neonatal adaptation syndrome than other SSRIs. Preferred if sertraline causes side effects.
• Fluoxetine (Prozac): Longer half-life. Can build up in the baby’s system. Not first choice unless other options fail.
• Paroxetine (Paxil): Avoid during pregnancy. Linked to a higher risk of heart defects. Not recommended.
• Mood stabilizers like lithium and lamotrigine: Can be used under close monitoring. Valproate? Never. It carries a 10.7% risk of major birth defects.
• Benzodiazepines: Avoid unless absolutely necessary. Even short-term use can cause withdrawal in newborns. If used, limit to 5-7 days with weekly psychiatrist follow-up.

The National Pregnancy Registry for Psychiatric Medications has tracked over 15,000 pregnancies. Their 2023 data confirms: sertraline and escitalopram show no significant increase in major malformations. Paroxetine is the only SSRI with a clear red flag.

How Coordination Actually Works: The 5-Step Protocol

Good coordination isn’t luck. It’s a system. ACOG’s 2023 guidelines outline a clear, step-by-step process:

1. Preconception planning: If you’re thinking about getting pregnant, schedule a joint visit with your OB/GYN and psychiatrist at least 3-6 months before trying. This is when you adjust meds safely. Don’t wait until you’re pregnant.
2. First coordination meeting: By 8-10 weeks gestation, both providers should review your current meds, dosages, and mental health history. Use the ACOG Reproductive Safety Checklist to rate 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 in crisis or adjusting doses. Pregnancy changes how your body processes drugs-plasma volume increases by 40-50%, kidney filtration jumps 50%. Your dose may need to go up.
4. Standardized communication: Use a shared template that includes: medication name, dose, protein binding (sertraline is 98%), placental transfer coefficient, lactation risk category, and any side effects. This isn’t bureaucracy. It’s clarity.
5. Postpartum and breastfeeding plan: Don’t wait until after birth to decide. Plan ahead. Sertraline is safest for breastfeeding. Most women can continue their dose without stopping. Your baby’s pediatrician should be in the loop too.

One woman in Project TEACH NY’s 2023 report stopped sertraline after conflicting advice. Within weeks, she had a severe postpartum episode and ended up hospitalized. That’s preventable.

Barriers You’ll Face-and How to Beat Them

Even with perfect guidelines, real life gets messy. Here are the biggest roadblocks-and how to overcome them:

• Insurance delays: 57% of privately insured women wait more than 14 days for prior authorization to see a psychiatrist. Call your insurance company yourself. Ask for a case manager. If they delay, ask for an appeal form. You have rights.
• Electronic health record (EHR) gaps: If your OB/GYN uses Epic and your psychiatrist uses Cerner, they might not see each other’s notes. Bring printed copies of your med list and dosages to every appointment. Write it down. Keep a copy.
• Provider reluctance: Some OB/GYNs aren’t trained in psych meds. Some psychiatrists don’t know pregnancy pharmacokinetics. That’s why you need to advocate. Say: “I need both of you to talk. Here’s the ACOG guideline. Can we schedule a joint call?”
• Stigma: “I don’t want to be seen as someone who’s ‘medicated’ during pregnancy.” But untreated depression is stigmatizing too. It affects bonding, feeding, sleep, and your ability to care for your newborn. Medication isn’t weakness. It’s protection.

Kaiser Permanente’s integrated model shows what’s possible: 89% of patients report high satisfaction when both providers meet together. That’s the gold standard.

What to Do If Your Providers Won’t Coordinate

If your OB/GYN says, “I’ll handle it,” and your psychiatrist says, “I can’t prescribe during pregnancy,” you’re stuck. Here’s what to do:

• Ask your OB/GYN for a referral to a maternal-fetal medicine specialist with mental health training. These doctors are trained to manage complex cases.
• Call your psychiatrist’s office and ask if they work with the Project TEACH program. It’s a free consultation service in many states that connects OB/GYNs with psychiatrists.
• Use the National Pregnancy Registry (pregnancyregistry.org). They provide free safety data to providers and can help you get a second opinion.
• Request a telehealth consult with a perinatal psychiatrist. Many now offer virtual visits with OB/GYNs present.

You’re not asking for special treatment. You’re asking for standard care.

Breastfeeding and Medications: What You Need to Know

Many women stop their meds when they start breastfeeding-out of fear. But that’s often the wrong choice. The risk of relapse is higher than the risk of medication exposure through milk.

Sertraline is the top choice for breastfeeding. Less than 1% of your dose reaches your baby. That’s less than what’s found in infant formula. Escitalopram is next. Fluoxetine? Avoid if possible-it lingers longer in the baby’s system.

Monitor your baby for sleepiness, poor feeding, or jitteriness. These are rare but possible. If you see them, call your pediatrician and your psychiatrist. Don’t stop cold turkey. Taper slowly under supervision.

And yes-you can pump and dump if you’re on a medication with higher transfer, like benzodiazepines. But that’s rarely needed. Most antidepressants are safe.

What’s Changing in 2025?

The field is moving fast. In 2024, the FDA updated labeling for sertraline to say: “Coordination with obstetric provider recommended for dose adjustment beginning at 20 weeks gestation due to increased clearance.” That’s huge. It means the drug maker itself is telling doctors to work together.

AI-driven risk models are being tested in trials like PACT, which will use genetic testing to predict which meds work best for your body. By 2025, some clinics will use algorithms that predict relapse risk based on your history, genetics, and hormone levels.

And CMS now gives clinics a 5% reimbursement bonus if they document coordinated care in 90% of perinatal mental health cases. That’s pushing hospitals to make it standard-not optional.

Final Thought: You’re Not Alone

There’s no shame in needing help. You’re not failing your baby by taking medication. You’re protecting them. The safest medication during pregnancy isn’t always the one with the fewest side effects. Sometimes, it’s the one that keeps you alive, present, and able to hold your child.

Start today. Write down your meds. Call your OB/GYN. Ask if they’ve ever coordinated with a psychiatrist on a case like yours. If not, offer to help them set it up. Bring the ACOG guidelines. Show them the data. You’re not asking for permission. You’re asking for the care you deserve.