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Within the past 30 years, through ongoing technology and portability developments, real-time (b-mode) ultrasonography (RTU) has increasingly become a valuable diagnostic tool in assessing the female reproductive tract in swine. Initially applied in swine production to visually determine pregnancy status, RTU use has expanded to include assessment of the peri-pubertal and mature non-pregnant females as well. Transabdominal and transrectal modalities to visualizing the reproductive tract in swine have been reported with the transabdominal approach more common due to the fact of its ease of accessibility, animal/personnel safety, and reduced time to perform. Adjustable frequency transducers are preferred as they allow optimization of image quality at various depths. If a single transducer frequency must be selected, a 5 MHz probe provides the best versatility for visualizing the reproductive tract in swine. Other basic requirements for ultrasound equipment which will be used on commercial swine farms include being light weight and easy to handle, readily cleanable and disinfectable, long battery-life, and good durability. When using RTU for pregnancy determination, diagnosis is based upon a combination of the animal’s breeding records, the presence of embryonic fluid, and, depending upon gestational stage, fetal structures. If RTU is used as a diagnostic tool in assessing reproductive problems in an individual or a group of animals, sonographic evaluation of both the uterus and ovaries is performed. Tissues are delineated and assessed based upon their echogenicity, echotexture, and size. Uses of RTU in clinical practice may include assessment of delayed puberty, prolonged wean-to-estrus interval, absence of post-weaning estrus, herd disruptions in conception and farrowing rates, vulval discharge, peripartum and puerperal disorders. This review aims to provide an overview on principles and clinical uses of RTU with respect to application to address female reproductive performance issues in commercial swine operations.