It is a sobering fact that mishaps during the administration of anesthesia sometimes have a way of initiating problems which escalate step by step to a situation of total disaster for the patient. Inexperience and poor judgment often lie behind such tragedies and the following case report is presented not only as an illustration of this, but also as a useful lesson. The authors only became involved in this case after the anesthesiologist concerned made available his account of the clinical events together with the hospital records. For obvious reasons the anesthesiologist's name has not been given, but he has given his full permission to publish this case. A case report is presented in which a healthy 31-year-old a term para II, requested epidural anesthesia for an elective Cesarean section for pelvic disproportion. Repeated attempts to perform epidural anesthesia were necessary. Eventually she developed acute pulmonary edema and resuscitation was not successful. Both mother and fetus died.