We Do Abortions Here: A Nurse's Tale

by Sallie Tisdale

Harper's Magazine, October, 1987, 66-70.

We do abortions here; that is all we do. There are weary, grim moments when I think I cannot bear another basin of bloody remains, utter another kind phrase of reassurance. So I leave the procedure room in the back and reach for a new chart. Soon I am talking to an eighteen-year-old woman pregnant for the fourth time. I push up her sleeve to check her blood pressure and find row upon row of needle marks, neat and parallel and discolored. She has been so hungry for her drug for so long that she has taken to using the loose skin of her upper arms; her elbows are already a permanent ruin of bruises. She is surprised to find herself nearly four months pregnant. I suspect she is often surprised, in a mild way, by the blows she is dealt. I prepare myself for another basin, another brief and chafing loss.
"How can you stand it?" Even the client asks. They see the machine, the strange instruments, the blood, the final stroke that wipes away the promise of pregnancy. Sometimes I see that too: I watch a woman's swollen abdomen sink to softness in a few stuttering moments and my own belly flip-flops with sorrow. But all it takes for me to catch my breath is another interview, one more story that sounds so much like the last one. There is a numbing sameness lurking in this job: the same questions, the same answers, even the same trembling tone in the voices. The worst is the sameness of human failure, of inadequacy in the face of each day's dull demands.

In describing this work, I find it difficult to explain how much I enjoy it most of the time. We laugh a lot here, as friends and as professional peers. It's nice to be with women all day. I like the sudden transient bonds I forge with some clients: moments when I am in my strength, remembering weakness, and a woman in weakness reaches out for my strength. What I offer is not power, but solidness, offered almost eagerly. Certain clients waken in me every tender urge I have—others make we wince and bite my tongue. Both challenge me to find a balance. It is a sweet brutality we practice here, a stark and loving dispassion.

I look at abortion as if I am standing on a cliff with a telescope, gazing at some great vista. I can sweep the horizon with both eyes, survey the scene in all its distance and size. Or I can put my eye to the lens and focus on the small details, suddenly so close.   In abortion the absolute must always be tempered by the contextual, because both are real, both valid, both hard. How can we do this? How can we refuse? Each abortion is a message of our failure to protect, to nourish our own. Each basin I empty is a promise—but a promise broken a long time ago.

I grew up on the great promise of birth control. Like many women my age, I took the pill as soon as I was sexually active. To risk pregnancy when it was so easy to avoid seemed stupid, and my contraceptive success was part of the promise of social enlightenment. But birth control fails far more frequently than laboratory trials predict. Many of our clients take the pill; its failure to protect them is a shocking realization. We have clients who have been sterilized, whose husbands have had vasectomies; each one is a statistical misfit, fine print come to life. The anger and shame of these women I hold in one hand, and the basin in the other. The distance between the two, the length I pace and try to measure, is the size of an abortion.

The procedure is disarmingly simple. Women are surprised as though the mystery of contraception, a dark and hidden genesis, requires an elaborate finale. In the first trimester of pregnancy, it's a mere few minutes of vacuuming, a neat tidy up. I give a woman a small yellow Valium, and when it has begun to relax her, I lead her into the back, into bareness, into the stirrups. The doctor reaches in her, opening the narrow tunnel to the uterus with a succession of slim, smooth bars of steel. He inserts a plastic tube and hooks it to a hose on the machine. The woman is framed against white paper that crackles as she moves, the light bright in her eyes. Then the machine rumbles low and loud in the small windowless room; the doctor moves the tube back and forth with an efficient rhythm, and the long tail of it filled with blood that spurts and stumbles along into a jar. He is usually finished in a few minutes. They are long minutes for the woman. Her uterus frequently reacts to its abrupt emptying with a powerful, unceasing cramp, which cuts off the blood vessels and enfolds the bleeding tissue.

I am learning to recognize the shadows that cross the faces of the woman I hold. While the doctor works between her spread legs, the paper drape hiding his intent expression, I stand beside the table. I hold the woman's hands in mine, resting them just below her ribs. I watch her eyes, finger her necklace, stroke her hair. I ask about her job, her family; in a haze she answers me; we chatter, faces close, eyes meeting and sliding apart.

I watch the shadows that creep up unnoticed and suddenly darken her face as she screws up her features and pushes a tear out each side to slide down her cheeks. I have learned to anticipate the quiver of chin, the rapid intake of breath and the surprising sobs that rise soon after the machine starts to drum. I know this is when the cramp deepens, and the tears are partly the tears that follow pain—the sharp, childish crying when one bumps one's head on a cabinet door. But a well of woe seems to open beneath many women when they hear that thumping sound. The anticipation of the moment has finally come to fruit; the moment has arrived when the loss is no longer an imagined one. It has come true.

I am struck by the sameness and I am struck every day by the variety here—how this commonplace dilemma can so display the difference of women. A twenty-one-year-old woman, unemployed, uneducated, without family, in the fifth month of her fifth pregnancy. A forty-two-year-old mother of teenagers, shocked by her condition, refusing to tell her husband. A twenty-three-year-old mother of two having her seventh abortion, and many women in their thirties having their first. Some are stoic, some hysterical, a few giggle uncontrollably, many cry.

I talk to a sixteen-year-old uneducated girl who was raped. She has gonorrhea. She describes blinding headaches, attacks of breathlessness, nausea. "Sometimes I feel like two different people," she tells me with a calm smile, "and I talk to myself."

I pull out my plastic models. She listens patiently for a time, and then holds her hands wide in front of her stomach.
"When's the baby going to grow up into my stomach?" she asks.

I blink. "What do you mean?"

"Well," she says, still smiling, "when women get so big, isn't the baby in your stomach? Doesn't it hatch out of an egg there?"

My first question in an interview is always the same. As I walk down the hall with the woman, as we get settled in chairs and I glance through her files, I am trying to gauge her, to get a sense of the words, and the tone, I should use. With some I joke, with others I chat, sometimes I fall into a brisk, business-like patter. But I ask every woman, "Are you sure you want to have an abortion?" Most nod with grim knowing smiles. "Oh, yes," they sigh. Some seek forgiveness, others offer excuses. Occasionally a woman will flinch and say, "Please don't use that word."

Later I describe the procedure to come, using care with my language. I don't say "pain" any more than I would say "baby." So many are afraid to ask how much it will hurt. "My sister told me"—" I heard." "A friend of mine said"—and the dire expectations unravel. I prick the index finger of a woman for a drop of blood to test, and as the tiny lancet approaches the skin she averts her eyes, holding her trembling hand out to me and jumping at my touch.

It is when I am holding a plastic uterus in one hand, a suction tube in the other, moving them together in imitation of the scrubbing to come, that women ask the most secret question. I am speaking in a matter-of-fact voice about "the tissue" and "the contents" when the woman suddenly catches my eye and asks, "How big is the baby now?" These words suggest a quiet need for a definition of the boundaries being drawn. It isn't so odd, after all, that she feels relief when I describe the growing bud's bulbous shape, its miniature nature. Again I gauge, and sometimes lie a little, weaseling around its infantile features until its clinging power slackens.

But when I look in the basin, among the curdlike blood clots, I see an elfin thorax, attenuated, its pencilline ribs all in parallel rows with tiny knobs of spine rounding upwards. A translucent arm and hand swim beside.

A sleepy-eyed girl, just fourteen, watched me with a slight smile all through her abortion. "Does it have little feet and little fingers and all?" she'd asked earlier. When the suction was over she sat up woozily at the end of the table and murmured, "Can I see it?" I shook my head firmly.

"It's not allowed," I told her sternly, because I knew she didn't really want to see what was left. She accepted this statement of authority, and a shadow of confused relief crossed her plain, pale face.
Privately, even grudgingly, my colleagues might admit the power of abortion to provoke emotion. But they seem to prefer the broad view and disdain the telescope. Abortion is a matter of choice, privacy, control. Its uncertainty lies in specific cases: retarded women and girls too young to give consent for surgery, women who are ill or hostile or psychotic. Such common dilemmas are met with both compassion and impatience: they slow things down. We are too busy to chew over ethics. One person might discuss certain concerns, behind closed doors, or describe a particularly disturbing dream. But generally there is to be no ambivalence.

Every day I take calls from women who are annoyed that we cannot see them, cannot do their abortion today, this morning, now. They argue the price, demand that we stay after hours to accommodate their job or class schedule. Abortion is so routine that one expects it to be like a manicure: quick, cheap, and painless.

Still, I've cultivated a certain disregard. It isn't negligence, but I don't always pay attention. I couldn't be here if I tried to judge each case on its merits; after all, we do over a hundred abortions a week. At some point each individual in this line of work draws a boundary and adheres to it. For some physicians the boundary is a particular week of gestation; for another, it is a certain number of repeated abortions. But these boundaries can be fluid too: one physician overruled his own limit to abort a mature but overly malformed fetus. For me, the limit is allowing my clients to carry their own burden, shoulder the responsibility themselves. I shoulder the burden of trying not to judge them.

This city has several "Crisis pregnancy centers" advertised in the Yellow Pages. They are small offices staffed by volunteers, and they offer free pregnancy testing, glossy photos of dead fetuses, and movies. I had a client recently whose mother is active in the anti-abortion movement. The young woman went to the local crisis center and was told that the doctor would make her touch her dismembered baby, that the pain would be the most horrible she could imagine, and that she might, after an abortion, never be able to have children. All lies. They called her at home and at work, over and over and over, but she had been wise enough to give a false name. She came to us a fugitive. We who do abortions are marked by some as impure. It's dirty work.

When a deliveryman comes to the sliding glass window by the reception desk and tilts a box toward me, I hesitate. I read the packing slip, assess the shape and weight of the box in light of its supposed contents. We request familiar faces. The doors are carefully locked. I have learned to half glance around at bags and boxes, looking for a telltale sign. I register with security when I arrive, and I am careful not to bang a door. We are all a little on edge here.

Concern about size and shape seem to be natural, and it's the relief that follows. We make the powerful assumption that the fetus is different from us, and even when we admit the similarities, it is too simplistic to be deduced by form alone. But the form is enormously potent—humanoid, powerless, palm-sized, and pure, it evokes an almost fierce tenderness when viewed simply as what it appears to be. But appearance, and even potential, aren't enough. The fetus, in becoming itself, can ruin others; its utter dependence has a sinister side. When I am struck in the moment by the contents in the basin, I am careful to remember the context, to note the tearful teenager and the woman sighing with something more than relief. One kind of question though, I find, considerably trickier.

"Can you tell what it is?" I am asked, and this means gender. This question is asked by couples, not women alone. Always couples would abort a girl and keep a boy. I have been asked about twins, and even if I could tell what race the father was.

An eighteen-year-old woman with three daughters brought her husband to the interview. He glared first at me, then at his wife, as he sank lower and lower in the chair, picking his teeth with a toothpick. He interrupted a conversation with his wife to ask if I could tell whether the baby would be a boy or a girl. I told him I could not.

"Good" he replied in a slow and strangely malevolent voice, "'cause if it was a boy I'd wring her neck."

In a literal sense, abortion exists because we are able to ask such questions, able to assign a value to the fetus which can shift with changing circumstances. If the human bond to child were as primitive and unflinchingly narrow as that of other animals, there would not be abortion. There would be no abortion because there would be nothing more important than caring for the young and perpetuating the species, no reason for sex but to make babies. I sense this sometimes, this wordless organic duty, when I do ultrasounds.

We do ultrasounds, a sound-wave test that paints a faint, gray picture of the fetus, whenever we're uncertain of gestation. Age is measured by the width of the skull and confirmed by the length of the femur or thighbone; we speak of pregnancy as being a certain "femur length" in weeks. The usual concern is whether a pregnancy is within the legal limit for an abortion. Women this far along have bellies which swell out round and tight like trim muscles. When they lie flat, the mound rises softly about the hips, pressing the umbilicus upward.

It takes practice to read an ultrasound picture, which is grainy and etched as though in strokes of charcoal. But suddenly a rapid rhythmic motion appears—the beating heart. Nearby is a soft oval, scratched with lines—the skull. The leg is harder to find, and then suddenly the fetus moves, bobbing in the surf. The skull turns away, an arm slides across the screen, the torso rolls. I know the weight of a baby's head on my shoulder, the whisper of lips on ears, the delicate curve of a fragile spine in my hand. I know how heavy and correct a newborn cradled feels. The creature I watch in secret requires nothing from me but to be left alone, and that is precisely what won't be done.

These inadvertently made beings are caught in a twisting web of motive and desire. They are at least inconvenient, sometimes quite literally dangerous in the womb, but most often they fall somewhere in between—consequences never quite believed in come to roost. Their virtue arises and falls outside their own nature: they become only what we make them. A fetus created by accident is the most absolute kind of surprise. Whether the blame lies in a failed IUD, a slipped condom, or a false impression of safety, that fetus is a thing whose creation has been actively worked against. Its existence is an error. I think this is why so few women, even late in a pregnancy, will consider giving a baby up for adoption. To do so means making the fetus real—imagining it as something whole and outside oneself. The decision is a rejection; the pregnancy has become something to be rid of, a condition to be ended. It is a burden, a weight, a thing separate.

Women have abortions because they are too old, and too young, too poor, and too rich, too stupid, and too smart. I see women who berate themselves with violent emotions for their first and only abortion, and others who return three times, five times, hauling two or three children, who cannot remember to take a pill or where they put the diaphragm. We talk glibly about choice. But the choice for what? I see all the broken promises in lives lived like a series of impromptu obstacles. There are the sweet, light promises of love and intimacy, the glittering promise of education and progress, the warm promise of safe families, long years of innocence and community. And there is the promise of freedom: freedom from failure, from faithlessness. Freedom from biology. The early feminist defense of abortion asked many questions, but the one I remember is this: Is biology destiny? And the answer is yes, sometimes it is. Women who have the fewest choices of all exercise their right to abortion the most.

Oh, the ignorance. I take a woman to the back room and ask her to undress; a few minutes later I return and fined her positioned discreetly behind a drape, still wearing underpants. "Do I have to take these off too?" she asks, a little shocked. Some swear they have not had sex, many do not know what a uterus is, how sperm and egg meet, how sex makes babies. Some late seekers do not believe themselves pregnant; they believe themselves impregnable. I was chastised when I began this job for referring to some clients as girls: it is a feminist heresy. They come so young, snapping gum, sockless and sneakered, and their shakily applied eyeliner smears when they cry. I call them girls with maternal benignity. I cannot imagine them as mothers.

The doctor seats himself between the woman's thighs and reaches into the dilated opening of a five-month pregnant uterus. Quickly he grabs and crushes the fetus in several places, and the room is filled with a low clatter and snap of forceps, the click of the tanaculum, and a pulling, sucking sound. The paper crinkles as the drugged and sleepy woman shifts, the nurse's low, honey-brown voice explains each step in delicate words.

I have fetus dreams, we all do here: dreams of abortions one after the other; of buckets of blood splashed on the walls; trees full of crawling fetuses. I dreamed that two men grabbed me and began to drag me away. "Let's do an abortion," they said with a sickening leer, and I began to scream, plunged into a vision of sucking, scraping pain, of being spread and torn by impartial instruments that do only what they are bidden. I woke from this dream barely able to breathe and thought of kitchen tables and coat hangers, knitting needles striped with blood, and women all alone clutching a pillow in their teeth to keep the screams from piercing the apartment-house walls. Abortion is the narrowest edge between kindness and cruelty. Done as well as it can be, it is still violence—merciful violence, like putting a suffering animal to death.

Maggie, one of the nurses, received a call at midnight not long ago. It was a woman in her twentieth week of pregnancy; the necessarily gradual process of cervical dilation begun the day before had stimulated labor, as it sometimes does. Maggie and one of the doctors met the woman at the office in the night. Maggie helped her onto the table, and as she lay down the fetus was delivered into Maggie's hands. When Maggie told me about it the next day, she cupped her hands into a small bowl—"it was just like a little kitten," she said softly, wonderingly. "Everything was still attached."

At the end of the day I clean out the suction jars, poring bloods into the sink, splashing the sides with flecks of tissue. From the sink rises a rich and humid smell, hot, earthy, and moldering; it is the smell of something recently alive beginning to decay. I take care of the plastic tub on the floor, filled with pieces too big to be trusted to the trash. The law defines the contents of the bucket I hold protectively against my chest as "tissue." Some would say my complicity in filling that bucket gives me no right to call it anything else. I slip the tissue gently into a bag and place it in the freezer, to be burned at another time. Abortion requires of me an entirely new set of assumptions. It requires a willingness to live with conflict, fearlessness, and grief. As I close the freezer door, I imagine a world where this won't be necessary, and then return to the world where it is.