Stacey Warnecke, 30, had been undergoing a free birth at her Melbourne home with unregistered doula Emily Lal and her husband Nathan on September 29.
A free birth, unlike a home birth where a registered midwife is present, is done intentionally without any medical professionals.
Her baby boy Axel was healthy but Ms Warnecke's condition soon rapidly declined.
She was rushed to Frankston Hospital after appearing hot, pale, gasping for air and going in and out of consciousness.
Doctors worked desperately to save her, but she died of blood loss from a postpartum haemorrhage, the Victorian Coroners Court was told.
After the death, senior hospital staff convened a "red light" meeting, Bayside Health Peninsula executive Shyaman Menon told the court on Wednesday.
An issue was raised at the meeting about Ms Lal's language during the new mother's birth, despite the doula identifying herself as a friend and not having any medical training.
"The language used was more than what a general public member would understand," Associate Professor Menon said.
The concern was around what advice was or was not provided during the birth and he was obligated to refer Ms Lal to police following concerns she was a "public health risk".
Ms Lal gave evidence at the inquest on Tuesday after being granted immunity from prosecution and defended her decision not to provide police with a statement.
Despite limited data available, the number of free births in Victoria appears to be increasing, Paediatric Infant Perinatal Emergency Retrieval director Alexis Shub told the inquest.
Reports to PIPER over adverse outcomes from home births and free births had increased from seven in 2023, to nine in 2024, 20 in 2025, with already 11 cases up to May 31 this year.
"There is ... a feeling that rates of harm are increasing," Associate Professor Shub said.
Assoc Prof Shub said the rise of free births could be due to a perception obstetricians and midwives are "doing things to women without their consent".
Frankston Hospital director of obstetrics and gynaecology Nisha Khot told the inquest postpartum haemorrhage is the most common complication of childbirth.
She said clinicians are trained to look for signs, including increased heart rate, decreased blood pressure, the woman feeling uneasy, uncomfortable, cold and clammy or losing lucidity.
In a triple-zero call, Ms Lal told the operator she believed Ms Warnecke may have been experiencing a panic attack and said she couldn't see any signs of further bleeding after the birth.
Dr Khot said the longer labour goes on - in Ms Warnecke's case it spanned days - the more likely a woman is to have a significant bleed after the birth.
"We may not always see the blood externally, we also know the blood we see we tend to underestimate how much it is," she said.
The inquest continues.
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