At our hospital we care for several high risk pregnancies which include known severe fetal anomalies prior to birth. Due to these severe fetal anomalies, vaginal delivery is contraindicated. These patients fall into the measure due to having a cesarean birth ( when nulliparous) due to the limited denominator exclusions. According to ACOG and SMFM guidelines, the recommendation for delivery is cesarean birth. Is there consideration for further review of the limited denominator exclusion for this population and adding them to the denominator exclusion list?