Objective: To evaluate umbilical cord blood ischemia-modified albumin (IMA) levels in cases of fetal distress (FD) and to explore fetal blood IMA levels regarding the route of delivery. Methods: Umbilical cord and maternal serum IMA concentrations were assessed in term 40 cases with cesarean section (CS) due to FD, 76 cases with elective repeat CS and 85 cases with noncomplicated vaginal delivery. Results: The maternal and umbilical cord IMA levels were significantly lower in vaginal deliveries when compared with CS cases either in FD or previous CS groups (p = 0.02). Although no statistically significant difference was found in IMA levels of CS groups (previous CS vs. FD), cord blood IMA levels tend to be higher in FD group. Neither demographic characteristics nor fetal outcome parameters were found to have any correlation with maternal IMA levels. However, umbilical cord IMA levels were found to be negatively correlated with 1th min Apgar scores (r = -0.143, p = 0.043). Conclusions: IMA seems to be responsive to hypoxic FD showing the highest levels in cases with severe fetal hypoxia. Higher levels of IMA in cases with elective repeat CS might indicate acute transient hypoxia and possible myocardial ischemia in these cases.