If the patient has an adhesive disease from prior surgeries, the surgeon may encounter adhesions involving such structures as the omentum, the bowel, the anterior abdominal wall, the bladder, and the anterior aspect of the uterus. In a gravid woman, unlike in a nongravid patient, the uterus is often encountered at this point immediately upon entry into the abdomen. After separating the rectus muscles, which run from cephalad to caudal, the surgeon enters the abdominal cavity through the parietal peritoneum. One is composed of aponeurosis from the external oblique rectus muscle, and the other is a fused layer that contains the aponeuroses of the transverse abdominis and internal oblique muscles. The anterior abdominal fascia usually consists of two layers. The next layer is the fascia overlying the rectus abdominis muscles. First, the skin is incised, followed by the subcutaneous tissues. To achieve a cesarean delivery, the surgeon must traverse all the layers that separate him/her from the fetus.
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