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 suffering multiple cardiac arrests after appearing hot, pale, gasping for air and going in and out of consciousness.
Doctors worked desperately to save her, including performing two separate surgeries - a hysterectomy and draining fluid that had pooled around her heart.
It was entire supply of Ms Warnecke's blood type was used up, but she died of blood loss from a postpartum haemorrhage, the Victorian Coroners Court was told.
After the death, senior and executive hospital staff convened a "red light" meeting.
The meetings, which would usually be called 24 to 48 hours after a significant incident, was called on the same day Ms Warnecke died, Bayside Health Peninsula executive Shyaman Menon told the court on Wednesday.
During the meeting, a senior hospital executive raised an issue about language Ms Lal had used during her care of the new mother, despite identifying herself as a friend.
"The language used was more than what a general public member would understand," he told the inquest.
"That raised a concern whether there was someone who had an element of knowledge providing that care."
The concern was around what advice was or was not provided during the birth at Ms Warnecke's home, and he was obligated to refer Ms Lal to police following concerns of a "public health risk".
Counsel assisting Rachel Ellyard asked if the concern was that Ms Lal had provided advice in circumstances where she didn't have medical training.
"Correct," he replied.
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 the triple-zero call, Ms Lal said she believed Ms Warnecke may have been experiencing a panic attack and said 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 baby is born.
"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 hearing continues.
