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The uterus consists of the serosal outer layer (perimetrium), the muscle layer (myometrium), and the inside mucosal layer (endometrium). In a patient with prior cesarean sections, the bladder may become difficult to separate from the uterus. If the surgeon desires to make a bladder flap, he or she must incise the vesicouterine peritoneum. Upon identifying the uterus, the surgeon can then identify the vesicouterine peritoneum, or vesicouterine serosa, that connects the bladder and the uterus. 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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