The baby girl died at Queensland's Sunshine Coast University Hospital the day after her "free birth" at a home with no midwife present on October 20, 2024.
The girl, referred to as Baby M, was born pale with no spontaneous limb movements nor attempts at crying, deputy state coroner Stephanie Gallagher said in her findings.
Baby M was her mother's second pregnancy that she carried to term.
"Baby M's mother reportedly felt traumatised after her first birth and planned to deliver Baby M at home with a midwife present," Ms Gallagher said.
The mother discontinued the services of a private midwife at 30 weeks gestation due to financial reasons and planned a free birth at home with her partner.
After Baby M was born largely unresponsive at 11.40pm, the family asked an off-duty paramedic friend for assistance, who was able to sustain a heartbeat using an oxygen mask.
Queensland Ambulance paramedics arrived on scene at 12.13am and continued resuscitation on Baby M, who was stabilised and taken to hospital with signs of oxygen deprivation and hypothermia.
"Baby M's condition did not improve despite continuous support," Ms Gallagher said.
"In consultation with her parents, a decision was made to cease resuscitation, and Baby M was declared life extinct at 2.42am."
Baby M died from asphyxia during birth caused by distress and meconium aspiration syndrome, Ms Gallagher found.
An autopsy found meconium, a thick liquid containing substances ingested and excreted by a foetus, in Baby M's lungs.
Ms Gallagher accepted expert evidence that Baby M and her mother received proper care from the private midwife and the hospital after disengaging from the public health system due to a previous traumatic birth.
"Birth trauma for women and their families is real, as exemplified by the NSW Birth Trauma enquiry held in 2024," Ms Gallagher said.
"Maternity care staff need to take this seriously and, when providing care, be mindful of the woman's past birth history, her wishes for the current pregnancy and provide comprehensive care for women that is respectful of their choices."
The NSW parliamentary inquiry found trauma-informed care, continuity of midwifery care with a known provider and informed consent were key to preventing birth trauma.
The landmark inquiry resulted in an apology from the health minister to affected women and adoption of all 43 recommendations.
Ms Gallagher decided against holding an inquest while extending her condolences to Baby M's family for their loss.
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