The categorization of compound presentations as a denominator exclusion for ePC-02 warrants reconsideration. Compound presentations, which involve the presence of a fetal extremity alongside the presenting part, should not be automatically excluded from vaginal delivery assessments. The management of labor and delivery following the discovery of such presentations can adhere to traditional obstetric principles, advocating for a conservative approach that prioritizes maternal and fetal well-being. Traditional obstetric care emphasizes minimizing unnecessary interventions while ensuring the safety of both mother and baby. Upon identifying a compound presentation, if the fetal head is well-engaged and the mother is stable, labor can often progress without immediate intervention. This conservative management approach is not only compatible with obstetric principles but also supports the notion that many compound presentations can be successfully navigated through standard delivery practices. In my experience from working in Labor & Delivery, compound presentations may be observed more commonly during vaginal deliveries compared to cesarean births. This frequency suggests that the presence of a compound presentation is not necessarily an indicator of a poor outcome, but rather a variation that can be managed effectively in a vaginal context. Recognizing this fact reinforces the argument that such presentations should not be viewed as grounds for exclusion from ePC-02 metrics. It is essential to acknowledge that compound presentations are often identified only once the baby is delivered. This means that excluding these cases from the denominator based on a potential complication undermines the reality of clinical practice, where many such presentations do not lead to adverse outcomes. By excluding these cases, we risk skewing data and undermining the value of ePC-02 as a measure of quality in obstetric care.  Notably, the Joint Commission’s PC-02 does not classify compound presentations as an exclusion. This precedent demonstrates a recognition of the safety and validity of managing such cases within vaginal delivery metrics. It is crucial for CMS to reconsider their stance and align with the principles established by the TJC, thereby ensuring consistency in quality measures across obstetric care. Excluding these cases not only risks misrepresenting the quality of care but also undermines the reality of clinical practice where many compound presentations are effectively managed. Their management can align with traditional obstetric principles through conservative and individualized care, which supports safe vaginal deliveries.