Women Less Likely to Receive Bystander CPR During Sudden Cardiac Arrest

And there may be one maddening reason why
Woman UnconsciousWomen are 27% less likely to receive bystander CPR for an out-of-hospital sudden cardiac arrest event than men. Why? There may be a very simple explanation: breasts.

The Training Manikin Problem

Most CPR training manikins come in various skin tones, with configurations ranging from preemie infants to obese adults. Unfortunately, the one thing most of them have in common is that they are all flat-chested. In fact, with the exception of one very specific manikin (the Life/Form CPARLENE), there aren’t any breasts to contend with when learning CPR.  Even the original CPR manikin - Rescusci-Annie, is decidedly unendowed. We need to start the conversation about how to change our perception of appropriate and inappropriate when it comes to life-saving procedures so the outcomes are positive for all genders. Slightly less than half the population is, for the most part, not flat-chested. In fact, many women are considerably the opposite. CPR is required for everyone who goes into sudden cardiac arrest (SCA), and yet the taboo of baring a woman’s chest in public and beginning CPR on her to save her life may sometimes cause men (and even women) to hesitate. A study of 600 participants in 18 different CPR sessions was conducted by Dr. Torben Becker of the University of Florida in Gainesville. He found that of those that were reluctant to step in and perform CPR, 14% said they were reluctant to expose a woman’s chest, and 6% said they were afraid they would be charged with sexual assault. Despite all efforts to lift that taboo by raising awareness of the importance of quality CPR and the use of an AED to treat SCA, women are less likely to receive the care they need from bystanders, which means they are statistically less likely to survive.

Proper steps for performing CPR and using an AED on women

  1. Determine if the person is unresponsive by tapping the person near the collar bone and shouting "Are you OK". If they are responsive but are clearly in need of medical attention, call 911 and stay with the patient.  If the person is unresponsive or not breathing normally, proceed with cardiac arrest rescue measures. 
  2. Call 911
  3. Retrieve or send someone for an AED
  4. Remove all clothing from the patient’s chest - this includes swimsuits, bras, sports bras, tank tops, and regular tops. If you need to, you can cut through clothing with the shears included in an AED’s response kit. Be sure to cut away from the person’s face.  Apply the AED electrode pads as indicated on the packaging.
    1. On most women, the breasts will fall to the side once clothing is removed. They will no longer be “in the way” of performing CPR and hand placement would be the same as on a man - two fingers above the bottom of the sternum, between the nipples. You may need to lift the left breast to accurately place the AED pad under it. Bras need to be cut for AED electrode pads to be placed properly.
    2. Some women may have smaller breasts that will not fall out of the way. As with a  man, hand placement is the sternum between the nipples. Since the bottom hand fingers are extended, they may touch the woman’s breast. 
    3. Some women may have had breast enhancement surgery wherein the breasts are more rigid, so they may be larger, but may not fall to the side. Again, hand placement is the same, the fingers will most certainly touch the woman’s breast, and CPR should be performed as accurately as possible.
  5. Follow the AEDs directions, performing CPR and pausing for analysis by the AED, until EMS arrives and takes over.

It's Not Inappropriate

CPR is a life-saving action to treat sudden cardiac arrest and increase the odds that a person will survive. There is nothing inappropriate about it, and bystanders are key players in the chain of survival. Unfortunately, if someone goes into sudden cardiac arrest while surrounded by a large number of people, the odds of them receiving immediate care is less likely since there may be a tendency by potential rescuers to believe there is someone more qualified nearby. Being prepared for an SCA emergency means understanding it truly can happen to anyone, regardless of age, ethnicity, physical fitness, or gender. Someone in cardiac arrest is unresponsive and not breathing, or not breathing normally. For all intents and purposes, they are dead. Anything you can do to help is better than doing nothing at all. That includes removing the person’s clothing to more accurately perform CPR and correctly attach AED electrode pads. It is not time to be prudish or worry about modesty. 

14 Responses to “Women Less Likely to Receive Bystander CPR During Sudden Cardiac Arrest”

October 16, 2019 at 8:38 am, M. J. Blanchard said:

Two fingers above the sternum is old school. Finding the tip of the xiphoid process is time consuming and then measuring the two finger distance is also wasting time. Maintaining a visual image of the relation between the lower half of the sternum and the nipple line of an anatomically correct training manikin is faster and more accurate. Take note that an elderly (previously) well endowed female will no longer have an anatomically correct placement of nipples and older obese men, especially, have issues with gravity, as well.

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October 16, 2019 at 1:18 pm, T Bachamp said:

I agree with M. J. Blanchard. I just completed CPR/AED recertification where the instructor made a point that we should be using the “normal” nipple line and not worrying about the xiphoid process. This is the instruction from the American Heart Association.

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October 16, 2019 at 2:41 pm, Tracey Tarver said:

Comments on the nipple line and correct hand placement is noteworthy but besides the POINT! The fact that responders are more hesitant to help a woman because of breast is something that WE INSTRUCTORS need to point out in our training classes. Going forward I will put ample time into bringing this information to the attention of the students, along with the knowledge of how the Good Samaritan Act is STATE specific.

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October 16, 2019 at 2:44 pm, Tracey Tarver said:

WE INSTRUCTORS need to take time to cover this point in our classes. CPR IS FOR EVERYONE. Also point out that the Good Sam Act is STATE specifically

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October 17, 2019 at 6:21 am, S.Sievert said:

Based on a suggestion from another instructor, half of my CPR manikins are now dressed with not only a shirt, but a bra. It is amazing how many students remove the shirt and just stall. They look up, they look around, unsure what to do, some even get embarrassed. Even though they know they are supposed to remove all clothing, the act of removing a bra, even on a manikin, is uncomfortable. Thank you for this article – I plan to share it!

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October 17, 2019 at 6:37 am, Josephine Adelfio said:

Nipple line does NOT work for finding the lower half of the breast bone – straight facts, both men and women have different nipple lines. Women’s breast fall the side of the chest when laying flat, so the nipple line should NOT be a BASIC guideline for compression’s. It is not difficult to find the lower half of the breast bone. If you do compression’s on the xiphoid process, it will break and splinter and cause damage to the heart and other organs in the area. As an instructor, I teach my students for both BLS and HeartSaver this information. Straight up term nipple line should only be used on children and infants. GOOD Sam Act is used specifically by state, if your not sure read the laws to your state. Everyone should learn CPR / BLS you might have to save a family member, man or woman. If you are not trained and it is an emergency call 911 they will walk you through it.

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October 17, 2019 at 7:10 am, John Culp said:

This title is misleading and thus it is missing the point. The original article this one is based off of and hyperlinked in the first sentence is titled “Men Are More Likely Than Women to Receive CPR in Public, Study Finds.” “In public” is the elephant in the room that is not being addressed.
While it is true manikins could be more realistic and lifelike, the training manikin is not the problem. Manikins are not hairy, sweaty, and smelly yet men are helped. More people need to be trained to perform CPR and on how to use an AED. The original article points out CPR in public is still rare. It occurs in approximately 37 percent of all cardiac events that occur in public. Although people are less likely to help someone they do not know, The more who are trained increases the likelihood of someone stepping up to help.
Another issue is the culture we live in. It is taboo to look at let alone touch the breast of women you do not know in public and it simply makes people uncomfortable. There is not a significant difference between men and women when the researchers looked at in-home CPR so it can’t be a manikin issue. For at home CPR the study found 35 percent of women and 36 percent of men who received CPR. However, we’re only at 35 and 36 percent which is unacceptable!
We as instructors have to continue to raise the awareness and importance of CPR. We also need to encourage our students to encourage others to receive AED/CPR training. CPR is absolutely critical during cardiac arrest no matter where it occurs.

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October 17, 2019 at 6:49 pm, Robin Lewis said:

Being a woman as an Instructor I’ve always covered this issue or concern. Breasts consist of fatty tissue that will not be in the way. It’s tissue which falls to the side and will not interfere with compressions. I tell students to use the nipples a marker which is lower half of the chest, center of the chest, “nipple line”. Nothing changes. It about life or death. I tell my students “I’d rather be nude and alive than dead and covered”. That always gets a laugh and a nod. I also tell to students take into consideration and provide privacy as much as possible meaning direct someone to move people away from the scene.

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March 21, 2020 at 8:54 am, Alaster Osborne said:

I never had this brought to our attention in my first aid course though I know I would take the same actions to a woman as I would a man when it comes to saving life’s! I recently went and bought an AED after my business partner Electrocuted Himself with 1600vlts and put himself into an off site cardiac arrest I didn’t have an AED and was doing CPR On him for 20 min prior to an ambulance showing up his heart was down for 35 mins he lived to make a full recovery against the odd of like a 3% survival rate! The first aid training saved his life even though mine was expired and only level one it all came back in a heart beat!! For Marc that was so true! Thank you to all you first aid instructors you are incredible people!!

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May 03, 2020 at 4:55 am, Ashley said:

I was looking for a website with anyone with the same concerns as me and this is the closest i got. My whole concern is the
exposing of woman’s breast, what if someone records it and that women’s breast are on the internet, i understand you have to take off all clothing but if this happened to me in school obviously kids would record, i know its bad and disrespectful to even think of recording a situation where someone can die but its the generation we live in, kids record everything, so like i said if this happened to me in school and had to do CPR right then and there and the person exposed me, obviously everyone would see the video of me i would die of embarrassment and pretty sure any girl would too, i would’ve rather NEVER getting the CPR than being exposed to be honest. Just my opinion.

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May 04, 2020 at 10:36 am, AED Superstore said:

Hi Ashley,
As a woman myself, I can understand your concern; however, if CPR is not done quickly and correctly, the odds of recovering from a cardiac arrest are slim to none. In the event you or anyone at your school should go into cardiac arrest, there should be a policy to steer students away from the rescue – not just because of the recording, but because it will help the rescuers concentrate and will keep the students from witnessing what is ultimately an intense procedure – possibly ending in the patient’s death. Not really something children should be witnessing if it can be avoided. One thing to keep in mind is that embarrassment is temporary, but death is permanent.

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July 03, 2020 at 9:22 pm, Trevan Deeley said:

As a First Aid instructor this question often comes up with the most discerning of students, under the protection of the Samaritan Act as a “Certified First Aider” and witnesses that will affirm in court the rescuers honest and good intentions to save a life of a person, the issue of bared breasts should be no issue at all.
The other issue to respect the culture and gender of the patient can easily be dealt with by, Yes remove the Bra quickly to attach AED Pads as needed in proper positions and just as quickly place a dry cloth over the chest to protect ones modesy etc, then simply place the heel of one hand on top of the other hand, locate lower half of Sternum of chest and start compresions as taught as per instructions of First Aid DRSABCD

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July 06, 2020 at 8:05 pm, Andy said:

As a former firefighter/EMT and current instructor I agree this is an issue that needs to be addressed more in training. As a rookie, the first time I had to do CPR was on a woman and in all my 10 years of training up to that point didn’t address this. Thankfully I had the other more experienced firefighters with me to show me what to do. Now every time I teach a class I cover this topic enough so my students will hopefully not shy away from performing CPR. I believe hand placement is the best method instead of using the nipple line, as this can vary greatly depending on your patient.

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August 27, 2020 at 5:49 am, AED on Women: Should bras be removed? – ARASCA Medical Equipment Trading LLC said:

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