Background: Acute colonic pseudo-obstruction, or Ogilvie's syndrome, is a rare presentation in the postoperative or postpartum period, particularly following cesarean section, associated with significant morbidity and mortality, as high as 45% if the signs and symptoms are not rapidly recognized. The hallmark is marked abdominal distention over a very short period with no mechanical obstruction. Initially, when the dilatation is within 10–12 cm, it can be managed conservatively. However, long-standing ileus can result in ischemia and gangrenous changes in the cecum and spontaneous rupture, hence, surgical intervention might be warranted. Case description: This is a rare presentation in a post-lower segment cesarean section of colonic pseudo-obstruction with sepsis. A 28-year-old female para 1 who underwent a lower segment cesarean section, presented on day 3 postsurgery with sudden onset diffuse abdominal pain and multiple bilious vomiting episodes. Laboratory results showed elevated C-reactive protein (CRP) of 186.46 mg/L. Abdominal X-ray revealed grossly dilated small bowel loops. CT abdomen showed small bowel loops dilated and fluid-filled (max caliber measuring ~6.55 cm) with tapering at the level of terminal ileum near the ileocecal junction, there was no evidence of an abrupt cutoff. Initially the diagnosis was Ileus and hence was managed conservatively. But as the patient was not improving, exploratory laparotomy was done, and intraoperatively grossly dilated edematous small and large bowel loops, multiple serosal tears, and necrotic cecal area were seen. The patient underwent limited ileo-colectomy and end ileostomy, specimen was sent for histopathology, which showed features of focal transmural necrosis and hemorrhage of the cecum and distal ileum, not following the radiological concordance-ileus. Her postoperative course had persistent dyselectrolytemia, elevated CRP protein till postoperative day 3, and surgical site infection—culture reports suggestive of Enterococcus faecium. She was discharged on day 14 after laparotomy. On a 1.5-year follow-up, she underwent adhesiolysis of ileal loops twice in the first year itself, but was disease-free later. Conclusion: Even a minor surgical procedure such as a lower segment cesarean section, presenting postpartum with distended bowel loops, can escalate into a surgical emergency and is frequently an undetected diagnosis. With a functioning ileocecal valve, the cecum and colon undergo significant dilation, resulting in vascular compression within the wall, leading rapidly to ischemic necrosis and perforations, hence, in such cases with a primary diagnosis as paralytic ileus, the very possibility of turning into Ogilvie's syndrome should be considered. Prompt and accurate diagnosis followed by timely surgical intervention are imperative for averting peritonitis and long-term complications.