Tandem placement within the uterine cavity can be a tedious affair in Intracavitary brachytherapy and blind insertion of the tandem may result in suboptimal tandem placement or uterine perforation and reduce the control rate of the tumor locally. Although routine real time ultrasound guided tandem placement has shown better results, it is seldom practiced. Ultrasound (US) is a simple imaging modality that is readily available in most departments and allows real-time visualization of applicators. We present our study with aim to evaluate the role of routine real-time intraoperative trans-abdominal ultrasound guided tandem placement in terms of decreased complication rates, improved implant geometry and increased operator efficiency. A total of 62 patients were randomized and assessed prospectively at our institution who underwent intracavitary brachytherapy for various stages of cervix cancer between October 2019 to March 2020 with 31 patients undergoing US guided tandem placement versus 31 patients who did not undergo the same. A total of 124 applications were analyzed and Cervical dilation, tandem selection and subsequent insertion were guided by trans-abdominal ultrasound with confirmation of the final placement of the applicator on US followed by CT imaging for treatment planning. Thereafter, the perforation rates and the applicator suitability for patient anatomy were assessed. Role of intervention in case of perforation, the time taken for the application, complications following the perforation were also assessed. The rate of perforation in the US assistance arm was 3% applications versus 12% in the non-US assistance arm. The cervical os could be easily identified visually, which was then confirmed with ultrasound guidance. The length of the uterine canal changed in 25 patients during the subsequent brachytherapy application with help of US assistance. Visualization of patient anatomy during the procedure aided the selection of suitable tandem length and angle in 39 of cases and resulted in optimal applicator selection and placement. The average insertion time was 19 minutes versus 27 minutes favoring US assistance (p = 0.012). The need for the assistance from radiology and gynecologic oncology for identification of the uterine cavity was not required in any of the cases suggesting excellent feasibility of US use. The bladder d2cc (EQD2) was 71.4Gy vs 74.8Gy (p = 0.034) and Rectum d2cc was 74.9Gy vs 77.8Gy (p = 0.023) favoring the US assisted arm. The study emphasizes on the routine use of US assistance to improve optimal applicator selection and proper applicator geometry and thereby, reduce the reinsertion and perforation rates. US assistance also helps reduce the procedure time and out-of-department referrals. It is an accurate, fast, easily available, and cost-effective method.