This case involves a twenty-seven-year-old postpartum patient who presented to labor and delivery with chorioamnionitis. She was being treated as an outpatient after delivery with oral antibiotics. Four to five days after delivery, the patient developed shortness of breath. A chest x-ray was obtained, and no abnormalities were appreciated. Respiratory therapy (RT) was then consulted. RT gave a dose of nebulized albuterol to dilate the airway. After administering the dose, the RT technologist departed. The patient symptoms worsened, and she pressed the nurse call button, but no one, immediately, responded. When the nurse checked back on the patient, she was in severe respiratory distress. Her condition deteriorated to cardiopulmonary arrest and ACLS protocols were initiated. The patient expired shortly thereafter.